SE2EO The healthcare organization supports nurses' participation in local, regional, national, or international professional organizations.
Provide two examples, with supporting evidence, of improvements resulting from a change in nursing practice that occurred because of clinical nurse involvement in a professional organization. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1
NAME OF INITIATIVE
Lactation Consultant Program
BACKGROUND/PROBLEM
Organizational Support in Nurse’s Professional Organization Participation
In July of 2012, Clinical Nurses Carey Acosta RN, Celina Gonzalez, RN, and Laura Houwers RN, expressed a desire to improve breastfeeding rates, standardize breastfeeding education and promote a more Baby-Friendly environment. Acosta and Gonzalez were lactation counselors and Houwers was a licensed midwife. Houwers and Gonzales were members of Association of the Woman’s Health Obstetrics and Neonatal Nurses (AWHONN). Through their affiliation with AWHONN, they have access to its clinical practice guidelines (Guidelines for Professional Registered Nurse Staffing for Perinatal Units, 2010) and reviewed them in relation to their department’s existing practice. They identified an area of opportunity in meeting the guideline regarding availability of a lactation consultant. AWHONN recommends a lactation consultant be available for every 1000 births. Homestead Hospital averaged about 1500 births per year, yet did not have an in-house lactation consultation. AWHONN, American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), World Health Organization (WHO), American College of Nurse-Midwives (ACNM), American Congress of Obstetricians and Gynecologists (ACOG), and Healthy People 2020 endorse breastfeeding as the preferred method of infant feeding. Additionally, Healthy People 2020 targets a goal of 81.9% breastfeeding rate by the year 2020. The rate of breastfeeding initiation on the Perinatal unit in early 2012 was averaging 19%. The national average is 66% according to the United States Department of Health and Human Services (HHS). Evidence suggests that access to a lactation consultant improves initiation rate and the likelihood of the breastfeeding continuation once the patient transitions to the home setting. Evidence also shows that breastfeeding improves the long- and short-term health for both mother and baby.
GOAL STATEMENT(S)
The goal was to improve breastfeeding rate by 10% from baseline, from 19% to 29%.
The measure used to demonstrate improvement was the Exclusive Breast Milk Feeding component of The Joint Commission (TJC) Prenatal Core Measure set. TJC defines exclusive breast milk feeding as: “newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.” Breast milk feeding includes expressed mother’s milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast. While breastfeeding is the goal for optimal health, it is recognized that human milk provided indirectly is still superior to alternatives. The formula utilized in calculating exclusive breast milk feeding was:
Percent of Infants with Exclusive Breast Milk Feeding = Infants Receiving Exclusive Breast Milk Feedings divided by Total Mothers Indicating Desire to Breastfeed times 100.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
Perinatal Services Director Jan Weatherspoon, RN, conducted a gap analysis and formulated a plan to develop a lactation program for Homestead Hospital and to include a full-time lactation consultant driving the initiative. She presented her proposal to Chief Nursing Officer and Vice President Gail Gordon, RN and Chief Executive Officer Bill Duquette who approved it. Weatherspoon revised the FY 2013 Perinatal Services budget to accommodate a 0.9 full-time equivalent (FTE) for a certified lactation resource nurse position. Lactation Resource Clinical Nurse Carey Acosta, RN, was hired in July 2012. Acosta achieved the following wins within the first few months of hire:
- She shadowed lactation consultants at sister Baptist Health facilities in order to initiate a harmonized program structure and leverage expertise.
- She initiated the assessment and consultations with patients in August 2012.
- She rolled-out education to 100% of the nurses in the Perinatal Services department in September 2012, which included a pre- and post-test on their knowledge of breastfeeding practices and patient support. This was a 2 hour training class that was required and paid for by the unit.
- She performed one-on-one physician education with all of the obstetricians, pediatricians, neonatal nurse practitioners, and other interested physicians within the hospital.
- Acosta conducted free breastfeeding classes for the expectant families in the community as part of prenatal classes starting in February 2013.
- She spearheaded the initiation of the Baby-Friendly Initiative which included consultation with a community expert who provided $1500 worth of educational video and resource books for each area of the Perinatal Services.
- She revised the breastfeeding policy (HH-400-2640-2630-080) to incorporate the 10-steps to becoming a Baby-Friendly Hospital.
A year after assuming the role of lactation resource nurse, (August 2012 – August 2013), Acosta has seen 600 inpatient consults, 20 outpatient consults, and 3 employee consults. The overwhelming volume of consults justified the need for a part-time lactation resource which Clinical Nurse Laura Houwers, RN, IBCLC, assumed in October 2013. Acosta obtained her IBCLC certification in November 2013. The services offered by the lactation team have evolved to include a discharge hotline for continuity of lactation care among discharged patients. Patients were provided with refrigerator magnets that list important resource numbers including the lactation support phone number. Patients could speak directly to the lactation resource nurses or leave a message. The discharge hotline has received approximately 20 phone calls since April 2013, with 20 patients returning for additional lactation support. Lactation consultations were made available free of charge to employees as well as to patients admitted in other units and in the Emergency Department (ED). They provided consultation to a total of 6 inpatient and ED patients. They also corresponded with 5 patients via email.
Exhibit SE2EOa: Discharge Hotline Magnet
Acosta’s passion for improving breastfeeding practices extended beyond Homestead Hospital. She collaborated with Childbirth Educator Ana Cabrera, RN, and Research Nurse Specialist Shakira Henderson, RN, in creating a corporate breastfeeding group called, Breastfeeding System-wide Taskforce (BST). The goal of this team was to standardize breastfeeding practices and education across entities based on the most current evidence. Acosta, Cabrera and Henderson presented their proposal to the Patient Care Leadership Council (PCLC), consisting of all chief nursing officers (CNO) in the system, in August 2013. The CNOs received their idea enthusiastically and endorsed the formation of BST. Consequently, Henderson was appointed as Chair, Acosta as Co-Chair and Cabrera as the historian. The taskforce conducted their first meeting in December 2013.
PARTICIPANTS
Name/Credentials |
Years work experience/ Years Specialty Experience |
Title |
Department |
Role in the Team |
Carey Acosta, RN, IBCLC |
8 years / |
Lactation Resource Nurse |
Perinatal Services |
Team Leader; Educator |
Laura Houwers, BSN, RN, RNC-OB, IBCLC, LM |
24 years / |
Clinical Nurse; Part-time Lactation Resource Nurse |
Perinatal Services |
Member; Educator |
Celina Gonzalez RN, |
4 years |
Clinical Nurse |
Perinatal Services |
Member; Educator |
Jan Weatherspoon, MSN, RN, NEA-BC |
30 years / |
Perinatal Services |
Perinatal Services |
Mentor |
Gail Gordon, MSN, RN, NEA-BC |
45 years / |
Chief Nursing Officer (CNO) and Vice-President of Nursing |
Nursing Administration |
Executive Sponsor |
Bill Duquette |
30 years/ |
Chief Executive Officer |
Administration |
Executive Sponsor |
OUTCOME(S)
Exhibit SE2EOb: Percent of Infants with Exclusive Breast Milk Feeding among Mothers Desiring to Breastfeed
*Legend: USDHHS – United States Department of Health and Human Services
Analysis: The graph shows a significant increase in the exclusive breast milk feeding percentage among mothers desiring to breastfeed with the addition of full-time and part-time lactation resource nurses which have exceeded the goal for 3 consecutive quarters and the national benchmark for 2 consecutive quarters.
Summary Attachments/Hyperlinks/Evidences:
Exhibit SE2EOa: Discharge Hotline Magnet
Exhibit SE2EOb: Percent of Infants with Exclusive Breast Milk Feeding
Example 2
NAME OF INITIATIVE
Noninvasive Cardiac Output Monitoring (NICOM®)
BACKGROUND/PROBLEM
Early identification and aggressive treatment are primary goals in the treatment of severe sepsis and septic shock as identified in the Surviving Sepsis Guidelines for the Management of Severe Sepsis and Septic Shock. The guidelines state to administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L. The guidelines further state to give fluids to maintain a central venous pressure (CVP) ≥ 8mmHg or a superior vena cava mixed venous oxygen (SCVO2) of ≥ 70%.
At Homestead Hospital it is not often that CVP’s are ordered to be measured, and very rare that an SCVO2 is measured. Both of these measurements require invasive procedures by an advanced provider. The Intensive Care Unit (ICU) nursing staff perceived that patients with sepsis were not getting the recommended amount of fluid resuscitation, but they were unable to verify that with the Surviving Sepsis Guidelines recommended end points. Additionally, they were concerned that the severity adjusted mortality ratio for severe sepsis averaged 1.25 in 2011 indicating that more patients died of severe sepsis at Homestead Hospital than predicted.
Historically, critical care clinicians assessed a patient’s response to fluid volume by measuring the central venous pressure (CVP) or pulmonary capillary wedge pressure (PCWP). Newer evidence has identified that pressure indices are not a good reflection of a patient’s fluid volume status (Kumar 2004; Marik 2008; Saugel 2011). The use of a central line or a pulmonary artery catheter also carries potential serious complications, and their use did not indicate an improvement in the patient’s outcome. Noninvasive hemodynamic monitoring devices have been developed and shown to be as good as or superior to CVP or PCWP monitoring and provide the volumetric measures. The evidence has identified that using volumetric indices such as stroke volume (SV), stroke volume index (SVI), and stroke volume variation are better indices of fluid responsiveness (Marik 201; Squara 2007). Furthermore, using these monitors to assess changes in stroke volume index with the passive leg raise maneuver (PLR) or a fluid bolus is an evidence-based indicator of fluid responsiveness (Cavallaro, 2010).
NICOM® is a noninvasive cardiac monitoring technology manufactured by Cheetah Medical. It provides continuous, non invasive, hemodynamic insight, delivering real time tracking of cardiac output and other key hemodynamic parameters. Through the use of sensors placed on the torso, this device could measure and calculate the SV, SVI, cardiac output (CO), cardiac index (CI), peripheral vascular resistance (PVR) and peripheral vascular resistance index (PVRI). This device could also calculate the percentage of change in the SVI when a passive PLR maneuver was used or a fluid bolus was given. The change in the SVI is an indicator of fluid responsiveness. If the change is 10% or greater, this indicates that patient is fluid responsive.
Clinical Nurses Involvement in Professional Organization
Joyce Nealey, RN is a national member of the American Association of Critical Care Nurses (AACN) and pays for her professional dues. Because of her professional affiliation, Nealey is well-versed with best practices, which she came across through journal readings and networking with colleagues. She got introduced to NICOM® during a system-wide Critical Care Best Practice Committee meeting in March 2011, of which Nealey was a member. She was very enthused upon learning about it and brought the idea to her department. Her nurse leaders agreed to trial the device, and after the trial agreed to keep it. This became the impetus for the initiation of a good clinical bedside research among the ICU nurses.
GOAL STATEMENT(S)
To improve the severity adjusted mortality ratio for severe sepsis at Homestead Hospital to 1.0 or less.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
The product clinical application specialists from Cheetah Medical Company trained the ICU nurses on NICOM in December 2011. They also taught a group of super users who assisted with subsequent trainings and refresher sessions. Nealey was one of the super users. Several clinical nurses collaborated with Patient Care Manager Leslie Everett, RN and Assistant Vice President Ana Cabrera, ARNP in developing a nurse-driven protocol for NICOM®, which was approved by the ICU medical director and the Critical Care Committee in January of 2012. NICOM went live in the same month.
Also in January 2012, Clinical Nurse Specialist Rosemary Lee, ARNP and Nurse Scientist Maria Ojeda, ARNP met with the interested clinical nurses from ICU & Progressive Care Unit (PCU). The goal of the meeting was to identify a research project that clinical nurses could be actively involved in. The group met over several months to firm up their ideas. In one of the meetings, Nealey suggested that perhaps they could better manage the sepsis patients’ fluid requirements with NICOM and use it as a basis for their research study.
The team identified an area of opportunity after NICOM implementation. The hospitalists did not have a good understanding on how to use the parameters provided by NICOM. Thus, the team arranged for a Lunch & Learn in March 2014 with the Cheetah clinical application specialists teaching the hospitalists about the device and Lee reviewing the nurse-driven protocol.
Organizational Support in Nurse’s Professional Organization Participation
Critical Care Services nursing leaders encourage clinical nurses to be part of their professional organizations by sending them to conferences and exposing them to the benefits of membership. Homestead Hospital and Baptist Health South Florida (BHSF) also supports participation in professional organizations by providing venues for meetings. In March 2014, Everett sent Nealey and 3 other nurses to the regional Greater Miami Area Chapter of the AACN Miami Teaching Institute. At this meeting, Nealey was exposed to the latest information on sepsis and met the NICOM vendor. She was able to gather Additional Documentation and used it for the research project.
The ICU Research Team consisted of Lee, Nealey, Ojeda, Everett, Cabrera, Clinical Nurse Hector Matias, RN, and Clinical Nurse Laura Cox, RN. They worked on developing the research proposal and the IRB application, which took them some time. They eventually obtained Institutional Review Board (IRB) approval in May 2014. They titled the research as “Outcomes of Sepsis Patients Using the Noninvasive Cardiac Output Monitoring (NICOM) to Guide Fluid Resuscitation.” This was a retrospective matched case-control study to compare the mortality outcomes of septic patients who received fluid resuscitation via a nurse driven protocol that used non-invasive cardiac output monitoring to those that did not. Patients from 2009-August of 2011 were used for the group that did not receive non-invasive cardiac output monitoring. Patients from 2014-2015 would be used for the intervention group.
PARTICIPANTS
The members of NICOM Support Team were:
Name/Credentials |
Title |
Department |
Role in the Team |
Joyce Nealey, RN |
Clinical Nurse |
ICU |
Sepsis Champion |
Atiya Kuha, BSN, RN |
Clinical Nurse |
ICU |
NICOM super user |
Claudelle Stafford, RN |
Clinical Nurse |
ICU |
NICOM super user |
Laura Cox, RN, CCRN |
Clinical Nurse |
PCU |
NICOM super user |
Christine Edozie, MSN, RN, CCRN |
Clinical Nurse |
ICU |
NICOM super user |
Sophie Boudreau MSN, RN, CCRN |
Clinical Nurse |
ICU |
NICOM super user |
Hector Matias, MSN, RN |
Clinical Nurse |
ICU |
NICOM super user |
Rosemary Lee DNP, ARNP, ANP-BC, CCNS, CCRN |
Clinical Nurse Specialist |
ICU |
Sepsis Champion; |
Marcia McLean, BS, RN, CCRN |
Clinical Nurse |
ICU |
ICU Policy & Procedure Committee member; assisted in developing nurse-driven NICOM protocol |
Alex Valencia, RN |
Clinical Nurse |
ICU |
ICU Policy & Procedure Committee member; assisted in developing nurse-driven NICOM protocol |
Sonja Davidson, RN |
Clinical Nurse |
PCU |
ICU Policy & Procedure Committee member; assisted in developing nurse-driven NICOM protocol |
LaQuinta Roberts, BSN, RN, CCRN |
Clinical Nurse |
ICU |
ICU Policy & Procedure Committee member; assisted in developing nurse-driven NICOM protocol |
Dianne Henriques, RN, PCCN |
Clinical Nurse |
PCU |
ICU Policy & Procedure Committee member; assisted in developing nurse-driven NICOM protocol |
Leslie Everett BSN, RN, CCRN |
Patient Care Manager |
Critical Care |
Administrative support |
Ana Cabrera DNP, ARNP, ANP-BC, CCRN, NEA-BC |
Assistant Vice President of Nursing |
Nursing Administration |
Executive support |
Juan Lopetegui, MD |
Medical Director |
ICU |
Executive support |
Maria Ojeda, DNP, PhD-(c), MPH, ARNP, NP-C |
Nurse Scientist |
Nursing & Health Sciences Research |
Research support |
OUTCOME(S)
Exhibit SE2EOc: Mortality Ratio for Severe Sepsis in ICU
Analysis: Above graph depicts that the mortality ratio for severe sepsis in ICU remained consistently below 1 (except for 1 outlier) after the implementation of the NICOM nurse-driven protocol as evidenced by a decreasing calculated trend line.
The team’s next steps include continuing with the retrospective data collection for the intervention group to complete their research study.
Summary Attachments/Hyperlinks/Evidences
Exhibit SE2EOc: Mortality Ratio for Severe Sepsis in ICU