SE4 EO Nurses participate in professional development activities designed to improve their knowledge, skills and/or practices in the workplace. Professional development activities are designed to improve the professional practice of nursing or patient outcomes or both. May include interprofessional activities.
Provide one example, with supporting evidence, of nurses’ participation in a professional development activity that demonstrated an improvement in knowledge, skills and/or practice for professional registered nurses. 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 nurses’ participation in a professional development activity that was associated with an improvement in a patient care outcome. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1 – Improvement in Knowledge and Skills
NAME OF INITIATIVE
Stroke Education
BACKGROUND/PROBLEM
As described in SE1EO, Homestead Hospital has embarked on a journey to becoming a Stroke Ready hospital since spring 2012. The hospital-wide, interprofessional Stroke Steering Committee formed in September 2013 was composed of Nursing, Pharmacy, Laboratory, Imaging, Rehabilitation, Nutrition Services, Emergency Medical Staff, Neurology and Nursing Health Sciences Research. The group was chaired by Patient Care Manager and Cardiovascular Patient Care Coordinator Joan Baker, RN, who has extensive experience and expertise in the care of the neuroscience patient as evidenced by her national board certification in this specialty for the past 29 years.
Best practices in stroke care stress the importance of timely intervention because of the finite window from symptom onset for the interventions to be effective in preventing or minimizing post-stroke sequelae. The staff’s ability to recognize stroke symptoms early and initiate treatment help contribute to meeting this acute treatment window. To realize this, the Stroke Steering Committee planned on rolling out a series of education interventions to improve nurses and hospital staff’s knowledge and skills on stroke care.
GOAL STATEMENT(S)
The Stroke Steering Committee’s overarching goal was to improve processes in early stroke recognition, timely diagnostic work up and patient outcomes. Specifically, using the Kirkpatrick model as a framework, they aimed to:
- increase nurses’ knowledge of acute stroke care as evidenced by improved scores on a 9 item pre-and post-stroke module test;
- improve nurses’ skills as evidenced by stroke symptom recognition and announcing a “stroke alert.”
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
Nurse’s Participation in Professional Development Activity
Even before the official inception of the Stroke Steering Committee, Baker rolled out the Emergency Department (ED) stroke protocol and checklist in November 2012. In collaboration with clinical nurse educators, she educated clinical nurses on the new stroke orders, protocols and checklists during staff meetings. The orders reflected the latest standards from the American Stroke Association (ASA).
To improve adherence with national guidelines and achieve best practice in patient outcomes, the Stroke Steering Committee collaborated with other Baptist Health facilities that had successfully implemented stroke initiatives or who were actively pursuing national stroke certification. These facilities used either the Joint Commission (TJC) or the Agency for Health Care Administration (AHCA) standards of stroke care. AHCA outlined a process for attestation and TJC also had guidelines for achievement of certification. In September 2013, the committee performed a gap analysis at Homestead Hospital using the AHCA standards. The team noted gaps in the nurses’ education on stroke assessment and care and lack of a stroke team to respond to stroke alerts. Despite the stroke alert algorithm and checklist education provided, adherence by the nurses, ED Technicians and some physicians to the protocol was very low. For this reason, the committee advocated for an expanded and more comprehensive education intervention to support the initial education.
The Stroke Steering Committee looked at regulatory agency and specialty organization recommendations in formulating the curriculum. TJC recommended that stroke centers educate nurses and providers in stroke pathophysiology, stroke symptom recognition, timely treatment and stroke prevention. The 2013 ASA guidelines outlined standards for stroke care. A 4-hour curriculum that followed these recommendations already existed in Baptist Health University (BHU), which was a computer-based training (CBT) program available on demand for all Homestead Hospital employees. Healthstream was the company contracted by Baptist Health South Florida (BHSF) to provide on demand education. A live instructor-led class could be offered as well upon the hospital’s request. A 1- hr tissue Plasminogen activator (tPA) module and an 8-hour National Institute of Health Stroke Scale (NIHSS) module were 2 of the programs recommended by the ASA, which were also available through Healthstream for the employees.
Baker, on behalf of the committee, advocated for paid nursing education modules by approaching hospital nursing leadership. In September 2013, she attended the Nursing Leadership Council (NLC) meeting and presented the education plan formulated by the committee. In addition, Baker lobbied for the need to educate the entire hospital staff on recognizing stroke symptoms. The NLC discussed at length the education criteria for nurses working in critical care, ED, and medical-surgical units. Ultimately, the Stroke Steering Committee obtained approval for the education to be mandatory. This meant nurses would be required to attend the class(es) and they would receive paid education time. The NLC agreed that the 4-hour stroke module would be mandatory for all emergency and medical- surgical nurses and the NIHSS would only be required for selected charge nurses and patient care supervisors in the ED and the ICU. Attendees would be paid for the allocated length of the program by their respective cost centers. Baker also presented the education plan to the Clinical Practice Council (CPC) in January 2014. She obtained support to move forward with the plan.
Subsequently, from February to May 2014, the Stroke Steering Committee rolled out a more expanded staff education as follows:
- A 30-minute mandatory online module of “What-I-Need-to-Know” (WINK) stroke badge buddy education for all Homestead Hospital employees on stroke symptoms recognition via Baptist Health University (BHU) was mandated.
- a 1-hour tPA (Activase) education module for Pharmacists, ICU and ED nurses via an online BHU module, a 3-hour NIHSS certification for all patient care supervisors, ED charge nurses, ED physicians and physician assistants via BHU or American Academy of Neurology website.
- A 4.5-hour stroke education module (live and online) titled, “Best Evidence-Based Stroke”, for all clinical nurses via an online BHU module, which offered 4.5 contact hours.
- An-8 hour NIHSS certification for all Providers in the ED. This was required by the ED medical director.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Joan F Baker, MSN, RN, CCRN, CNRN, CCPC |
Patient Care Manager and Cardiovascular Patient Care Coordinator |
Emergency Department |
Stroke Coordinator and Chair |
Rusette Arends, BSN, RN, CPEN |
Clinical Nurse Educator |
Emergency Department |
Educated ED nurses; member |
Rosemary Lee, DNP, ARNP, ACNP-BC, CCNS, CCRN |
Clinical Nurse Specialist |
Critical Care |
Educated ICU nurses; member |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and VP of Nursing |
Administration |
Executive Sponsor; member |
Aracely Olvera, BSN, RN, CMSRN |
Clinical Nurse Educator |
MS5 |
Educated MS5 nurses; member |
Marvia Mckenzie, BSN, RN |
Clinical Nurse |
Emergency Department |
Performed case reviews and staff education; member |
Nancy Doctura, BSN, RN |
Clinical Nurse |
Emergency Department |
Performed case reviews and staff education; member |
Leslie Everett, BSN, RN |
Nurse Manager |
Critical Care |
Member |
Ana Cabrera DNP, ARNP-BC, CCRN, NEA-BC |
Assistant Vice President of Nursing |
Nursing Administration |
Member |
Alicia Browne- Rowe, BSN, RN |
Special Projects Coordinator |
ICU |
Member |
Jose Guitian, PhD, ARNP |
Clinical Educator 2 |
Clinical Learning |
Four-hour Stroke Course Educator Data Collection |
Maria Ojeda, DNP, PhD-(c), MPH, ARNP, NP-C |
Nurse Scientist |
Nursing and Health Sciences Research |
Data Collection |
Andrea Draizer, SLP |
Speech Language Pathologist |
Rehabilitation Services |
Member |
Kurt Kadel, PT |
Director |
Rehabilitation Services |
Member |
Mary Shaw, RD |
Registered Dietician |
Dietary |
Member |
Elka Wiley, MD |
Neurologist |
Medical Staff |
Physician Stroke Champion; member |
Mark Weinstein, MD |
Emergency Medicine |
Medical Staff |
Physician Stroke Champion; member |
OUTCOME(S)
Improvement in Knowledge and Skills
In implementing an expanded and hospital-wide stroke education, the Stroke Steering Committee targeted to improve staff’s knowledge on early stroke detection and management. Since February 2014 to date, 1311 employees completed the “Stroke Badge Buddy” education, 160 clinical staff completed the “tPA (Alteplase)” module, 296 clinical nurses attended the” Best Evidence-Based Stroke” program.
Utilizing Kirkpatick’s model, the team evaluated the outcomes of stroke education as follows:
- Reaction: A sample of 55 post evaluation surveys were collected via survey monkey from February 2014 through May 2014. The survey evaluated the class on the following criteria with the corresponding average scores (higher was better):
- The presentation met the learning objectives – 90.91
- The content was related to my job – 89.09
- The instructor(s) were effective in delivering the course content in an easy to understand manner – 90.91
- The course content extended my knowledge of the topic – 92.73
- The teaching strategies (power point, hand-outs, visual aids) were effective – 90.91
Participants gave positive feedback on the course evaluation regarding the instructor’s knowledge, expertise and ability to deliver the content, as evidenced by the following comments:
“Instructor is extremely knowledgeable and informative.”
“I liked the way he involved the class in the discussion, input and feedback.”
“He definitely made the class very interesting and kept the audience's interest and attention.
“The presenter, very excellent delivery, very patient, class was informative and lively.”
The students indicated that they have learned valuable concepts in the areas of “Improved recognition of stroke symptoms; “Treatment of stroke in the acute phase; and “Most important question is ‘Last known normal’.” They described that they would apply new learning to clinical practice by teaching their patients about stroke risk factors; teaching their colleagues about stroke; and performing a better neurological assessment using Face-Arm-Speech-Time (FAST) and the Cincinnati Stroke Scale.
- Knowledge: The course instructor administered a 9-question pre-test at the beginning of the class held between February to May 2014. He administered the same set of questions at its completion.
Exhibit SE4EOa: Pre- and Post-Test Results of “Best Evidence-Based Stroke” Class
Analysis: Above graph shows improvement in knowledge after the course as evidenced by higher post- test scores among all 9 questions.
- Behavior/Skills – The committee monitored the number of Stroke Alerts (Stroke emergency code) called in order to glean the transfer of learning to practice.
Exhibit SE4EOb: Percent of Stroke Alert Called in Homestead Hospital
Analysis: Stroke education (February-May 2014) correlated with an increase in percent of Stroke Alerts called.
Summary of Attachments/Hyperlinks/Evidences
Exhibit SE4EOa: Pre- and Post-test Results of “Best Evidence-Based Stroke” Class
Exhibit SE4EOb: Percent of Stroke Alert Called in Homestead Hospital
Example 2 – Improvement in Patient Care Outcome
NAME OF INITIATIVE
Blood Management Program
BACKGROUND/PROBLEM
Transfusion of blood products is one of the most common interventions in the hospital setting. Although the blood supply is the safest it has ever been, transfusion of blood components remains a high-risk procedure. Each transfusion exposes patients to a variety of potentially serious complications. Therefore, unnecessary transfusions make little sense in view of the potential harm (Boucher, Hannon, 2007). A blood transfusion is in fact, a liquid transplant and there are safety concerns with adverse effects of allogeneic transplantation. Some of the adverse effects that can occur are infectious complications, febrile and allergic reactions, hemolytic transfusion reactions or other types of reactions such as systemic inflammatory response syndrome (SIRS), transfusion-related cardiac overload (TACO), transfusion-related acute lung injury (TRALI), and transfusion-related immunomodulation (TRIM) to name a few. (Institute for Healthcare Improvement [IHI] Expedition: The Appropriate Use of Blood Products 2011).
The New England Journal of Medicine published the Transfusion Requirements in Critical Care (TRICC) trial on February 11, 1999. In this landmark study, 838 anemic critically ill patients were prospectively randomized into one of two treatment strategies: transfuse at a Hgb level of 10 gm/dl, a very traditional approach to these challenging patients, or transfuse at a hemoglobin level of 7 gm/dl, which was a significant departure from common practice in 1999. The results changed the practice of transfusion medicine because the patients who were transfused at the more liberal trigger of 10 gm/dl had substantially worse outcomes than those transfused at the more conservative trigger of 7 gm/dl. Unfortunately, many practitioners have only a vague understanding of the complexities associated with blood transfusion therapy. Studies have shown that there is a variation in blood transfusion practices between institutions and even among different practitioners in the same institution (Boucher, Hannon-, 2007). The decision to transfuse is also often based more upon custom and habit rather than formal training and current evidence-based principles. (IHI Expedition: The Appropriate Use of Blood Products, 2011).
Nurse’s Participation in Professional Development Activity
The Joint Commission (TJC) proposed a new National Patient Safety Goal (NPSG) 16.01.01 to minimize the overuse of tests, treatments, and procedures and reduce the risk of patient harm including red blood cell transfusions. This was going to take effect on January 1, 2013. To proactively meet this requirement, Homestead Hospital participated in a 7-series IHI expedition in “The Appropriate Use of Blood Products” from February to May 2011. Performance Improvement (PI) Nurse Patricia Yulkowski, RN was one of the expedition’s participants. The educational activity, which offered 7 contact hours, elucidated how to build an effective blood product management program; test and implement changes that would produce cost savings; improve the quality of care; and nurses’ role in transfusion administration and safety. Yulkowski also attended in January 2012 a presentation that offered 1 contact hour on “Reducing Transfusions and Phlebotomy."
After the IHI expedition, Yulkowski looked at the ACS NSQIP summary report from 01/01/2011 – 12/31/2011 that looked at red blood cell (RBC) transfusions administered intraoperatively and postoperatively within 72 hours of surgery start time. Homestead Hospital’s transfusion rate was at 10.4% compared to the ACS NSQIP comparison group rate of 6.0%. It showed that Homestead Hospital had an opportunity for improvement with blood over usage intraoperatively and postoperatively. Yulkowski delved further and expanded the data collection on all RBC transfusions administered and the Hgb threshold the transfusions were ordered for the entire hospital. She broke down the data by medical specialty. It showed that Homestead Hospital was transfusing RBCs 69% of the time for a Hgb greater than 7. Best practice indicated that patients should be transfused at Hgb of less than 7 (IHI Expedition: The Appropriate Use of Blood Products, 2011). Yulkowski reported this information to the Critical Care Committee. In May 2012, a Blood Utilization Taskforce was formed. The team consisted of physician chiefs from various specialties, Critical Care Director and PI nurse. Yulkowski was named the hospital-wide champion and team leader.
GOAL STATEMENT(S)
The goal of the Blood Utilization Task Force was:
- Decrease transfusion rates for Hgb greater than 7g/dL by 2%, from 69% to 67% and by doing so
- Decrease adverse blood transfusion incidents.
Transfusion percentage was determined using the following formula:
% Hgb transfused greater than 7g/dL = |
Number of transfusions administered for a Hgb greater than 7 per month X 100 Total amount of transfusions administered for the entire month |
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
The team utilized the Plan-Do-Check-Act (PDCA) PI model to guide their inquiry and interventions.
Plan
The task force’s initial thrust was building blood transfusion order sets. This would streamline the blood transfusion ordering process and provide prompts for the ordering practitioner on the appropriate indications for the procedure. The hospital data Yulkowski collected showed that the medical specialty transfusing the most was the Internal Medicine group consisting mainly of the hospitalists. In 2012, they accounted for 48% of all transfusions ordered. Yulkowski decided to direct the educational intervention on the new evidence-based blood transfusion guidelines to this specialty.
Do
The blood transfusion order sets were approved in Homestead Hospital on September 2012. However, it needed to be approved at the Baptist Health system level in order to be built into the computerized physician order entry (CPOE). It took almost a year for the order set to be approved. Additionally, the CPOE build was further delayed due to a systems upgrade and the construction of a new electronic medical record (EMR) system that will replace the current system. In the interim, Yulkowski put together a Power Point presentation and articles with the new evidence-based transfusion guidelines. She presented it at the hospitalist’s meeting on February 2013. She also coordinated related Continuing Medical Education (CME) activities for the nurses and physicians held at the physician’s lounge and placed informational posters in strategic locations throughout the hospital.
Check
After the presentation to the hospitalists, the data showed immediate improvement but did not yield sustained results. Yulkowski presented this to the Critical Care Committee and to the rest of the Blood Utilization Task Force members. She decided to take another approach. In January 2013, she drilled down by individual Internal Medicine physician to determine where the outliers existed. This would enable the physicians to evaluate individual performance compared to their peers and promote practitioner accountability.
Act
In July 2013, Yulkowski met with Internal Medicine Chief and Head Hospitalist Dr. Mark Hernandez. She presented the scorecard for each physician and reiterated the new evidence-based transfusion guidelines. She followed this up with an email sent to the entire hospitalist group regarding the new guidelines with a graph showing the hospital’s transfusion rates. Hernandez invited Yulkowski to another hospitalist meeting on September 2013 to reeducate the physicians. At this meeting, she presented them with their individual transfusion rates compared to their peers. In October 2013, just one month after the presentation, the data already showed huge improvement with 50% of all blood transfusions transfused at a Hgb greater than 7. While waiting for the CPOE build of the transfusion order set to be completed and the go live date of Soarian (new EMR system), Yulkowski continued with data collection, physician reeducation and feedback on their transfusion rates on a monthly basis.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Patricia Yulkowski, BS, RN |
Performance Improvement Nurse |
Performance Improvement |
Team Leader |
Andrew Renshaw, MD |
Laboratory Medical Director |
Medical Staff |
Member |
Juan Lopetegui, MD |
Critical Care Medical Director |
Medical Staff |
Member |
Mark Hernandez, MD |
Internal Medicine Chief |
Medical Staff |
Member |
Ana Cabrera, DNP, ARNP, ANP-BC, CCRN, NEA-BC |
Director |
Critical Care |
Member |
OUTCOME(S)
Exhibit SE4EOc: Percent of Hemoglobin Transfused at >7 mg/dL
Analysis: Above graph shows that the team exceeded its goal of decreasing Hgb transfused at greater than 7 mg/dL by 2% from baseline as evidenced by continued and sustained improvement in the calculated trend line.
Improvement in Patient Care Outcome
Exhibit SE4EOd: Homestead Hospital Adverse Transfusion Reaction Incidents
Analysis: Above graph portrays a reduction in adverse transfusion reaction (shown in the calculated trend line) from an average of 2 to an average of 1 by reducing blood transfused at Hgb >7 mg/dL
References
ACS NSQIP. (December 2011). ACS NSQIP Post-Operative Occurrence Summary: Postop Occurrence Transfusion Intraop/Postop (72h of surgery start time) summary Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
ACS NSQIP. (June 2012). ACS NSQIP Post-Operative Occurrence Summary: Postop Occurrence Transfusion Intraop/Postop (72h of surgery start time) summary Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
ACS NSQIP. (December 2012). ACS NSQIP Post-Operative Occurrence Summary: Postop Occurrence Transfusion Intraop/Postop (72h of surgery start time) summary Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
ACS NSQIP. (June 2013). ACS NSQIP Post-Operative Occurrence Summary: Postop Occurrence Transfusion Intraop/Postop (72h of surgery start time) summary Homestead Hospital. [Online]. Retrieved from: http://site.acsnsqip.org/
Boucher, B.A. and Hannon, T.J. (No date). Review of Therapeutics, Blood Management: A Primer for Clinicians. Pharmacotherapy Volume 27, number 10, 2007: 1394-1411.
Carson, J.L., Carless, P.A., Hebert, P.C. (2013). Outcomes Using Lower vs. Higher Hemoglobin Thresholds for Red Blood Cell Transfusion. The Journal of the American Medical Association, January 2, 2013 – Volume 309, No.1, 83-84.
Hébert, P.C., Wells, G., Blajchman, M.A., Marshall, J., Martin, C., Pagliarello, G., Tweeddale, M., Schweitzer, I., Yetisir, E., et al. (1999). A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. New England Journal of Medicine 1999; 340:409-417February 11, 1999.
The Joint Commission. (2011). The Joint Commission Proposed National Patient Safety Goal (NPSG) 16.01.01: Minimize the overuse of tests, treatments, and procedures to reduce the risk of patient harm. Retrieved from: http://www.jointcommission.org/assets/1/6/CAH_NPSG_Overuse_Rpt_2011-11-14.pdf
Summary of Attachments/Hyperlinks/Evidences
Exhibit SE4EOc: Percent of Hemoglobin Transfused at >7 mg/dL
Exhibit SE4EOd: Homestead Hospital Adverse Transfusion Reaction Incidents
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