TL9EO Nurse leaders (exclusive of the CNO) use input from clinical nurses to influence change in the organization; Choose two of the three below (examples must be different from those provided in TL8
Provide one example, with supporting evidence, of change in the nurse practice environment that was influenced by the clinical nurse(s) communication with a nurse leader. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
OR
Provide one example, with supporting evidence, of change in patient experience that was influenced by the clinical nurse(s) communication with a nurse leader. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
OR
Provide one example, with supporting evidence, of change in nursing practice that was influenced by the clinical nurse(s) communication with a nurse leader. 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
NAME OF INITIATIVE
Improving Time to Initiate Therapeutic Hypothermia (TH)
BACKGROUND/PROBLEM
In 2005 the American Heart Association Guidelines for CPR and Emergency Cardiovascular Care stated that therapeutic hypothermia (TH) was recommended to improve the outcome for comatose adult victims of witnessed out-of-hospital cardiac arrest when the presenting rhythm was ventricular fibrillation. As a result, in 2008, Baptist Health South Florida’s Critical Care Best Practices Committee recommended that an education/ training program be developed by the Clinical Learning Specialty Practice department. The purpose of the program was to prepare the Emergency Department (ED) and Intensive Care Unit (ICU) nurses in managing patients meeting the criteria for TH. Clinical Learning initiated the education in July of 2008 in Homestead Hospital and throughout the health system.
In 2010, the American Heart Association Guidelines for CPR and Emergency Cardiovascular Care added a new section post-cardiac arrest care that recommended “the implementation of a comprehensive, structured, integrated, multidisciplinary system of post–cardiac arrest care in order to improve survival for victims of cardiac arrest who are admitted to a hospital after return of spontaneous circulation (ROSC). This treatment should include cardiopulmonary and neurologic support. Therapeutic hypothermia and percutaneous coronary interventions (PCIs) should be provided when indicated.” (Circulation 2010; 122; S768-S786). The fact that TH was now to be a standard of care for post-resuscitation management, rather than just a recommendation meant that the ED and the ICU would need to change their practices.
Despite the fact that the majority of Homestead Hospital’s ED and ICU nurses and physicians received education on therapeutic hypothermia in 2008 and 2009, only 5 patients between 2009 and 2011 had received therapeutic hypothermia (1 in 2009; 1 in 2010; and 2 in 2011).
Clinical Nurses Maria Gonzalez, RN, ED and Joyce Nealey RN, ICU identified that there were patients arriving in the ED and ICU who met criteria for TH and yet it was not initiated. Gonzalez and Nealey asked the help of ICU Clinical Nurse Specialist and Educator Rosemary Lee, ARNP to further investigate. They also spoke to several of their peers in their respective departments to identify barriers and gaps in care. They discovered that ED nurses were not comfortable in setting up hemodynamic monitoring lines and initiating TH. On the other hand, ICU nurses had difficulty in sorting through orders. Gonzalez, Nealey and Lee reviewed several records to validate their observations and noted that the amount of time it took to initiate TH was longer than the recommended 4 hours.
GOAL STATEMENT(S)
The goal of the ED and ICU team was to reduce the amount of time to initiate TH on individual cases from an average of 7 hours to 4 hours or less from the time of ROSC for those patients meeting the criteria.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
ED Clinical Nurse Educators Rusette Arends, RN & Karen Baez, RN together with Lee spoke to the ED and ICU medical directors and physicians concerning the missed opportunities for initiating TH. ED Medical Director Otto Vega, MD agreed to be more aggressive in identifying patients who met criteria and committed to reinforcing it among his ED practitioners. ICU Medical Director Juan Lopetegui, MD agreed to be available to assist in managing these patients and in identifying eligibility criteria.
Clinical Nurse Communication with Nurse Leader
Arends, Baez and Lee coordinated a simulation training session in August 2012 for the ED nurses that included setting up of pressure lines as well as all steps required to initiate TH. ICU Clinical Nurses Teri Weiser, RN and Nealey assisted in identifying the essential equipment needed, summarized orders in a checklist format and submitted the list of supplies to Arends and ED Director Sherine Craig, RN. Craig agreed to purchase the supplies on the list and a cart in order to have a “hypothermia cart” placed in the resuscitation room. This allowed staff to access needed equipment and supplies expeditiously. Nealey and Weiser also spoke to Patient Care Manager Leslie Everett, RN, about the need to have critical care nurses support the ED staff when taking care of TH patients. After garnering support from the ICU staff, Everett committed to having an experienced ICU nurse assist the ED staff with initiation of TH.
The team also agreed upon a new process for TH initiation as follows. When the ED would identify a TH patient, the ED charge nurse or Patient Care Supervisor (PCS) will call the ICU PCS and inform them of a potential TH candidate. The ICU PCS would go to the ED to assist in evaluating and initiating TH orders, which may include facilitating test and treatments (e.g. CT scan, x-rays, and laboratory work-up). If ICU nurses were immediately available, they would relieve the ICU PCS and assist in the care of the TH patient in the ED. If no immediate staff was available, the staffing office would be called to obtain additional nurses. Otherwise, the ICU PCS would re-evaluate staffing needs on the unit in order to provide help to the ED.
Through the collaboration of ED and ICU nurses, the number of cases identified for TH improved with a corresponding improvement in the time to initiation. However, in early 2013, two cases fell outside of the recommended time frame. ED and ICU clinical nurses once again identified a need to re-educate physicians and staff due to new staff members. Arends, Baez and Lee conducted another round of in-services for the ED nurses and physicians in March 2013.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Joyce Nealey, RN |
Clinical Nurse |
ICU |
ICU project leader |
Maria Gonzalez, RN |
Clinical Nurse |
ED |
ED project leader |
Rosemary Lee DNP, ARNP, ACNP-BC, CCNS, CCRN |
Clinical Nurse Specialist |
ICU |
Facilitator / Educator |
Karen Baez BSN, RN, CEN |
Clinical Nurse Educator |
ED |
Facilitator/ Educator |
Rusette Arends BSN, RN, CPEN |
Clinical Nurse Educator |
ED |
Facilitator/ Educator |
Leslie Everett BSN, RN, CCRN |
Patient Care Manager |
Critical Care |
Supported/ endorsed the process |
Ana Cabrera DNP, ARNP, ACNP-BC, CCRN, NEA-BC |
Director |
Critical Care |
Supported/ endorsed the process |
Sherine Craig, MSN, RN |
Director |
ED |
Supported/ endorsed the process |
Otto Vega, MD |
Medical Director |
ED |
Physician Champion |
Juan Lopetegui, MD |
Medical Director |
ICU |
Physician Champion |
OUTCOME(S)
Exhibit TL9EOa: Initiation of Therapeutic Hypothermia (TH) from time of Return of Spontaneous Circulation (ROSC)
*Legend: N.D. = No Data (No patients qualified for TH criteria in this particular month)
Analysis: Above graph demonstrates average time (in hours) of individual cases from time of ROSC to initiation of TH. The ED and ICU team met its goal of initiating TH within 4 hours or less of ROSC and sustained it for 7 months after they implemented education and process changes. Additionally, they noted an increase in the number of TH cases initiated - 22 cases within a 16-month time frame.
Summary of Attachments/Hyperlinks/Evidences
Exhibit TL9EOa: Initiation of Therapeutic Hypothermia (TH) from time of Return of Spontaneous Circulation (ROSC)
Example 2 – Change in Patient Experience
NAME OF INITIATIVE
Comfort Interventions during Coronary Computed Tomography Angiograms (CTA)
BACKGROUND/PROBLEM
CTA is a non-invasive test that allows the visualization of the coronary arteries using a 64 slice CT scanner, contrast media, and reconstruction of the scan. With the addition of another 64-slice scanner, CTA was being utilized more in Homestead Hospital. While working in imaging and assisting coronary CTA, Radiology Clinical Nurses Kelly Vazquez, RN and Margo Archer, RN noted that patients were exhibiting anxiety related to the procedure. They were particularly intrigued that the usage of Lopressor, a beta-blocker, was at times reaching the maximum intravenous dose of 20 milligrams according to the Radiology department’s protocol.. Though the scanning itself causes no pain, patients experience some discomfort or anxiety from having to remain still for several minutes; with IV placement; or being in an enclosed space.
Vazquez and Archer started brainstorming some ideas that could help decrease the patient’s anxiety levels, thus improving patient comfort and possibly decreasing the need for so much cardiac medication during the scan. In Homestead Hospital, Lopressor is the drug of choice used during coronary CT angiograms. This medication is primarily used to decrease the patient heart rates allowing a better defined image while avoiding blurred borders by limiting motion and artifact.
GOAL STATEMENT(S)
The goal for the project was to decrease the patients’ anxiety during CTA procedures through comfort interventions. The outcome measure for this would be the percentage of CTA patients using beta-blockers 15mg and higher prior to the procedure. This was calculated as:
% CTA patients receiving beta -blockers 15mg & higher = number of CTA patients who received beta-blockers 15mg & higher divided by total number of patients undergoing CTA who reported anxiety symptoms X 100.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Clinical Nurse Communication with Nurse Leader
In July 2013, Archer, who was also the Unit Practice Council (UPC) Chair-Elect, brought her and Vazquez’ ideas to the UPC members. The rest of the UPC members expressed enthusiasm in support of making it a UPC project. Thereafter, Vazquez communicated one-on-one with Patient Care Manager Raul Botana, RN, about the UPC project. As UPC Chair, Vazquez had regularly scheduled monthly meetings with Botana to discuss UPC projects and activities. He was enthused and fully supported their ideas. He provided guidance and assistance in collaborating with the Radiology department.
Vazquez and Archer started by reviewing the literature and used Kolcaba's Comfort Theory as the foundation to guide them in the project planning, data gathering, and developing ideas to promote patient comfort. According to the theory, comfort is an immediate desirable outcome of nursing care. (Kolcaba, 2010). They consulted with Nurse Scientist Maria Ojeda, ARNP for guidance, specifically, on the development of their data collection tool.
They started pre-data collection in September 2013. They utilized a convenience sampling of 30 patients for pre-intervention and 30 patients for post-intervention. Vazquez and Archer assessed the patients prior to the procedure using the survey tool they developed. To gather subjective data, they asked the patients if they were feeling anxiety, nervousness, fear, pain, sadness, happiness or calmness. They then observed the patients for behaviors that indicated they were anxious, nervous, scared, calm, happy or sad. Lastly, they checked the patients’ baseline heart rate. They collected their pre-data for 4 months. Patients who reported or assessed as calm were excluded from the sample size (N). The final pre-intervention N was 20.
The CT technicians and supervisors were very supportive of their ideas in promoting patient comfort levels and satisfaction. CT Supervisor Kimberly Fleitas supplied a new support wedge for the project. Vazquez and Archer started implementing comfort interventions at the very early part of February 2014 that included comforting language/voice, warm blankets, dim lighting, humor (if warranted), comforting touch, soothing music, eye mask, aromatherapy, and knee support wedge. They wanted to find out if these comfort measures would decrease the patient’s anxiety level, thus decreasing heart rate and the need for higher doses of beta-blockers. Out of the 30 patients surveyed, they included 22 as the final post intervention N.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Kelly Vazquez, RN, ONC, CMSRN |
Proficient Clinical Nurse |
Nursing Administration Clerical / Imaging |
Unit Practice Council Chair; co-project lead |
Margo Archer, RN |
Proficient Clinical Nurse |
Nursing Administration Clerical / Imaging |
Unit Practice Council Chair-Elect; co-project lead |
Pamela Burney, RN |
Proficient Clinical Nurse |
Nursing Administration Clerical / Imaging |
Member |
Raul Botana, MSN, RN |
Patient Care Manager |
Nursing Administration Clerical |
Provided support |
Maria Ojeda, |
Nurse Scientist |
Nursing and Health Sciences Research |
Mentored the project leads in the data collection and interpretation |
Kimberly Fleitas, BHS, RTRCT |
Imaging |
Imaging/CT |
Provided support |
OUTCOMES
Exhibit TL9EO: Percent of CTA Patients Receiving Beta-Blocker 15 mg and Higher in Radiology
Analysis: Above graphs shows a decrease in the use of higher/maximum beta blocker doses (15 mg and above) after comfort measures were implemented prior to the procedure indicating that the comfort interventions probably helped allay patient’s anxiety.
Additionally, patients welcomed the comfort interventions offered and took advantage of them as follows:
Comfort Interventions |
Percent of Patients Who Received |
Knee support wedge |
100% |
Warm blanket |
100% |
Comforting language |
90.5% |
Comforting touch |
90.3% |
Comforting voice |
85.7% |
Dim lighting |
85.7% |
Humor |
82% |
Soothing music |
19% |
Eye cover |
0% |
Based on the study results, Vazquez and Archer has since incorporated comfort interventions into their practice and continued exploring at other methods of enhancing patient comfort.
Summary of Attachments/Hyperlinks/Evidences
Exhibit TL9EO: Percent of CTA Patients Receiving Beta-Blocker 15 mg and Higher in Radiology