Within REACH -
CONFERENCE EDITION Volume 9│Issue 4 │December 2018
Carilion Medical Center, 1906 Belleview Ave, Roanoke, VA 24014 http://chsweb.carilion.com/nursserv/NursW eb.html nursingresearch@carilionclinic.org (540)266 -6216
The Value of Attending Conferences Mary C. Brewer, RD, RN, MSN, MBA - Carilion Department of Psychiatry
Not everyone learns the same way. In the old days, nurses had thick textbooks and little else for education. Luckily, the world has evolved to offer a myriad of ways we can polish our skills, learn new ones, or keep up with what’s changing in our profession. One of the best ways to do all of these is by participating in professional conferences. They offer opportunities for networking with colleagues who are already using new techniques, as well as those still just considering changes. You can hear from experts and sit in at roundtables to listen to ideas being bounced around. Whatever level of formality you prefer, you can find a conference to suit you. As a Registered Nurse and a Registered Dietitian Nutritionist, I keep up both licenses and so attend conferences on a variety of subjects. For example, I recently went to a large conference with 30,000 attendees that focused on natural foods, organics, and alternative and complementary health. This focus fit into both of my trajectories perfectly. Patients are asking me more about alternative and complementary healing, plant-based diets and organics, so I can use this information in both of my worlds, particularly as our consumer base becomes more educated. To get the most out of this very large conference, I plotted the main sessions that interested me beforehand, so that I would get as much out of the conference as possible. I also conferred with colleagues who were attending the conference, so that if we were interested in presentations scheduled at the same time, we could develop a plan for each of us to attend one of the sessions and share notes later. Finally, I didn’t worry about taking notes. With cellphones welcome at most conferences, I took photos of the slides and displays I most wanted to remember or refer to later. This is so much easier than scribbling away and missing half the slide, anyway. Webinars are also gaining popularity, and they have the advantage of being available to watch on demand. However you choose to stay up-to-date, remember to share the information you learn with your colleagues. Collaboration is the key to a strong profession.
~ Mary Carilion Clinic Roanoke Campus
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Join us as we celebrate our visit to the ANCC National Magnet Conference in Denver, CO!
2018 MagnetÂŽ Conference Center
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Carilion Roanoke Campus Awarded our 4th Magnet ® designation ! Carilion Clinic Roanoke Campus was designated a Magnet® facility for the fourth time in 2018 by the American Nurses Credentialing Center (ANCC). First earned in 2003, our Magnet® designation recognizes excellence and professionalism in nursing and is widely accepted as nursing’s highest honor. It was created to advance three goals:
1. Promote quality in an environment that supports professional practice. 2. Recognize excellence in the delivery of nursing services to patients. 3. Provide a mechanism for the dissemination of best practices in nursing. Living Magnet® Even before we earned Magnet® designation we knew that we lived by Magnet® principles; it’s one of the main reasons why we began the Magnet® journey. And, we continue to live Magnet® every day.
Magnet® designation is a testament to the incredible passion for nursing shown by our staff at all levels of the organization. The commitment, compassion, and hard work of everyone at Carilion make achievements like this possible. We don’t need awards and recognition to know our nurses are providing the highest quality patient care, but it’s an honor when national organizations agree. On October 18, 2018 we received notification from ANCC Magnet ® of our 4th designation! In addition, ANCC announced that Carilion Clinic Roanoke Campus was awarded an exemplar. Citing extraordinary achievement in internal dissemination of research and new knowledge, through a variety of strategies such as this Within REACH publication. It is rare for an organization to receive an exemplar and it is a testament to the extraordinary work of the Nursing Research Council and the staff in the Carilion office of Nursing Research EBP & Excellence.
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l-r: Rama Doucoure, BS; Susan Blankenship, MS, BSN, RN, PCCN; Jen Bath, MSN, RN, AGCNS-BC, CEN, TCRN; Angie McFaddin, MSN, RN; Suzanne Beels, MSN, RN, CCRN; Linda Siar, ADN, RN; Barbara Boggs, MSN, RN; Pam Lindsey, MSN, RN
Angie Mcfaddin, MSN, RN
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Introducing Carilion’s Presenters at the 2018 National Magnet® Conference Decreasing Readmissions by Implementing a Call Back Program Jennifer Bath, MSN, RN, AGCNS-BC, CEN, TCRN Trauma Services
Back to Basics: Reducing CAUTIs in an ICU Susan Blankenship,MS, BSN, RN, PCCN; Suzanne Beels, MSN, RN, CCRN; Heather Moreno, ADN, RN & Sharon Yeager, BSN, RN, CCRN 6 M Vascular ICU
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Session Highlights
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Session Title:
Reviewer: Jennifer Bath, MSN, RN, AGCNSBC, CEN, TCRN Unit: Trauma Services
Speaker & Organization: Cy Wakeman, MS, CSP President of Reality-Based Leadership General Session Keynote
Session Highlights: The opening keynote was a great start to the Magnet Conference. Cy Wakeman was very engaging and full of energy. She discussed many things during her hour lecture. She listed the different sources of drama as ego, accountability, buy in, change, and engagement. She found that people spend 2 ½ hours a day dealing with drama. Venting is the ego’s way of avoiding self-reflection, and self-reflection is the ultimate drama diffuser. If you’re venting it’s a sign you’ve stepped down. Stop judging and ask how you can help. Stop believing everything you think! All that you desire is natural once the drama is gone. Your suffering is optional and most always self-imposed. Our suffering is not caused by our reality; it is caused by the story we make up about our reality, the intentions of others, or the reasons why things are happening around us. So separate your reality from your suffering. Your level of accountability determines your level of happiness, so don’t hope to be lucky, choose to be happy. Change is not hard; it’s only hard for the unready. Don’t focus on what you can’t do, look at what you can do and what can make the situation better. Great leaders measure value, not performance. My favorite saying from Cy’s talk was, your ego is not your amigo! I enjoyed her so much I bought her book, and she signed it for me!
Take-Away for Carilion: For leaders, it is not about accountability, it’s about how we enable people. So we need to stop enabling staff. The more we coddle people, the more unready they are for change. A leader’s job is not to motivate, it’s to manage energy.
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Session Title:
Speaker & Organization: Reviewer: Angie McFaddin, MSN, RN Nursing Informatics Council Unit: Clinical Informatics
Vickie Adams, MSN, RN & Stephanie Burger, BSN, RN, PCCN The University of Kansas Hospital Kansas City, KS
Session Highlights: “Come experience an interactive game-based presentation. Participants will work in small groups using nursing practice knowledge, teamwork, & communication to escape. Attendees will learn how to create & implement an organization specific escape room” ~ ANCC 2018 Magnet® Conference Digital Program This was amazing! I would love to do something like this for the EPIC upgrade to get staff a little more engaged in the education. This was creative, and I think staff would be much more engaged if we can find creative ways like this to engage them in education. They used this strategy for their nurse residency program which really engaged the nurses in not only process and procedure but policy as well. It was not very expensive to set up. They estimated approximately $5 per nurse but that cost would go down as they continued to present the escape room education.
Take-Away for Carilion: Implement a similar process for the EPIC upgrade to engage staff in the education.
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Session Title:
Speaker & Organization: Reviewer: Angie McFaddin, MSN, RN Nursing Informatics Council
Unit: Clinical Informatics
Amy Kotter, MSN, RN, CPN, CPEN & Abigail Morse, MSN, RN, CNOR Cook Children’s Medical Center Fort Worth, TX
Session Highlights: “This presentation will describe an innovative 3-track nurse residency, its objectives, curricular content (notably perioperative track), and outcomes for meeting staffing needs, reducing orientation time, and increasing nurse retention/ satisfaction. “ ~ ANCC 2018 Magnet® Conference Digital Program Cook Children’s Medical Center created a 3-prong approach to nurse residency instead of running all new nurses through the same track. They were able to decrease orientation time and increase nurse satisfaction/retention. They specifically added a peri-op track which is really a different type of nursing than what is typically reviewed in nurse residency.
Take-Away for Carilion: Could our nurse residency program benefit from reviewing this model?
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Session Title:
Speaker & Organization: Reviewer: Barbara Boggs, MSN, RN Co-Chair: Nursing Research Council
Roy Brown, MLIS, AHIP & Dale Wright, MS, RN, ACNS-BC, PCCN
Unit: Resource Pool
VCU Health, Richmond, VA
Session Highlights: Virginia Commonwealth University Health Center began the process for their third Magnet® accreditation and found there were issues with documentation and tracking of evidence based practice policies that were being implemented throughout the organization. It was determined that there was confusion among nursing as to the difference between research, performance improvement and evidence based practice. An EBP portfolio was created beginning in 2014, and the project continued until 2018. The portfolio included implementing a nurse residency program, the identification of key nursing group programs, EBP competencies, (novice and proficient), and the use of Magnet champions to raise awareness on each unit. A Nursing Inquiry Process was developed to determine if projects fell under the heading of research, EBP or performance improvement. A survey was conducted among nurses prior to the implementation of the portfolio and then at the completion with regards to their knowledge, attitude and use of evidence based practice which showed positive results with the post survey responses. The next steps that VCU are considering with this portfolio include:
Improving the process based on feedback Exploring ways to have documents uploaded and collected in real-time Planning for a submission policy to place quality measures in the VCU Institutional repository that can be googled by all disciplinaries
Take-Away for Carilion: It would seem that Carilion Nursing and Carilion Nursing Research are ahead of the game as we have already implemented or are beginning to implement several of these processes. Evidence Based Practice (EBP) education began in Nursing Research Council in 2018. The Nurse Residency Program was initiated in 2017. Carilion IRB makes the determination if projects are research or QA/QI. An EBP PulseChek survey was provided to the Nursing Research Council to gauge the level of understanding regarding EBP.
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Session Title:
Reviewer: Linda Siar, ADN, RN Co-Chair: Nursing Recognition Council Unit: 12S Mother/Baby
Speaker & Organization: Ronald Malit, BSN, RN, CPAN, CAPA & Paschale Dorismond Parks, BSN, CPAN Houston Methodist Sugar Land Sugar Land, TX
Session Highlights: Postoperative nausea and vomiting (PONV) is a common side effect following surgery, with up to a third of all patients suffering moderate to severe nausea and vomiting following general anesthesia using inhaled anaesthetics(Hines et.al, 2018). Houston Methodist Sugarland (HMSL) Hospital’s Post Anesthesia Care Unit (PACU) noticed an increase in post-surgical patients reporting of PONV in their outpatient and inpatient surgical patients. A replication study was performed using a convenience sample of adult patients receiving surgery in their outpatient surgical suites. Patients receiving outpatient surgery were excluded from the study if they were under the age of 18, had allergies to the scents used and patient refusal. Those participating in the study received a commercial product containing an all-natural drug free blend of 4 essential oils: Peppermint, Lavender, Ginger and Spearmint. The result of the study showed a 60 percent decrease in the use of antiemetics compared to past practices that did not include the use of aromatherapy. The study concluded that aromatherapy was more effective in the treatment of mild to moderate nausea and minimally effective in the treatment of severe nausea. As a result of this study HMSL Hospital has developed a PONV management algorithm that gives the nurse autonomy to use aromatherapy on all patients during their post-operative care for PONV. HMSL hospital has plans to introduce aromatherapy to patients in Labor and Delivery and those receiving chemotherapy in the near future for the treatment of PONV.
Reference: Hines S, Steels E, Chang A, Gibbons K. Aromatherapy for treatment of postoperative nausea and vomiting. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD007598. DOI: 10.1002/14651858.CD007598.pub3.
Take-Away for Carilion: Potential for piloting the use of aromatherapy at CRMH, decreasing the use of antiemetics and thus decreasing cost.
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Session Title:
Speaker & Organization: Reviewer: Susan Blankenship, MS, BSN, RN, PCCN Unit: Education & Organizational Development
Whitney Smith, MSN, CHSE & Jana Strangfeld, BSN, CHSE
Children’s Hospital Colorado, Aurora,
Session Highlights: “Advanced technology in health care simulations offers new approaches to enhance patient safety and educational intitiatives. High-fidelity simulation in the lab and in-situ settings, video production, and methods to evaluate new equipment will be described” ~ ANCC 2018 Magnet® Conference Digital Program This session showed how one organization was using simulation for better patient outcomes and improved patient and staff satisfaction. By utilizing the simulation lab for patient/caregiver training, there was an improvement in 30-day readmits as well as increased confidence in the event of a complication occurring at home after discharge. The example given was a baby that had a respiratory event at home. They used a high fidelity manikin and let the family unit experience the event in the safety of the simulation center. They were also using simulation for staff education for medications like Narcan and for equipment such as new defibrillators.
Take-Away for Carilion: Would Carilion consider using our new SIM lab for patient/caregiver training? Have we looked at this with regards to our readmits?
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Session Title:
Speaker & Organization: Reviewer: Susan Blankenship, MS, BSN, RN, PCCN
Steven McPherson, BSN, RN Union Hospital of Cecil County, Elkton, MD
Unit: Education & Organizational Development
Session Highlights: “Learn how one organization used technology to greatly improve handoffs.” ~ ANCC 2018 Magnet® Conference Digital Program This was an innovative way that one hospital utilized computers in patients’ rooms for virtual handoffs. This was very similar to Facetime. By having the computer on wheels, the patient was able to ‘meet’ the nurse who would be taking over the care. The two nurses were also able to have face-to-face handoff which contributed to better communication of information. This was utilized for transferred patients, whether it was ED to Inpatient or unit to unit.
Take-Away for Carilion: As we continue to work to improve patient safety through handoff, creative approaches like this may be helpful.
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2018 Magnet® Conference KEYNOTE SPEAKERS!
Named one of the “Top 100 Leadership Experts to Follow”
About Cy....... Cy Wakeman is a dynamic international keynote speaker. She is a global thought leader with over 25 years experience cultivating a revolutionary new approach to leadership. Grounded in reality, Wakeman’s philosophy has helped organizations and individuals all over the world learn to ditch the drama and turn excuses into results.
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About Dr. Patch Adams....... Devoted to changing America’s healthcare system, Patch Adams brought his unique approach to medicine and care to the conference. Adams gained worldwide notoriety for bringing humor into patient care. Dr. Adams focuses on the joy and power of care, not only in the patient’s life, but also in the caregiver’s life.
About Aron....... Aron Ralston faced an unimaginable challenge with his life-or-death decision while trapped alone in a mountain crevasse. An ordinary man who was pushed to the extreme, he demonstrates the human capacity for the extraordinary, proving anyone can survive the most grueling circumstances. Ralston showcased how nurses can use this determination in their everyday work to beat the odds and achieve greatness within their practice.
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2017 MAGNET CONFERENCE HIGHLIGHTS
Be a Part of the Art! This year’s Magnet Conference featured the creation of a giant Luster Wall! “A luster what?” you ask? A Luster Wall! It’s a billboard-sized mosaic made up of the group photos and selfies taken at the conference and then posted to social media. Each time participants used the hashtags below, their photo appeared on the wall and you were automatically entered to win a #MagSwag bag valued at $50. Two prizes were given every day, and participants could post as many photos as they liked!
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ANCC 2019 ÂŽ Magnet Conference
The largest nursing conference in the United States is bigger and better than ever! Don't miss out on this energizing, inspiring, fun-filled event!
October 10-12, 2019 Orlando, FL
Carilion will be publicly recognized at the 2019 Magnet Conference for our 4th Redesignation!
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with Nursing Research
L-r: Shelly Feazell, BSN, RN, PCCN; Monica Coles, MSN, RN-BC, ACNS-BC; Allison Parkhurst, ADN, RN; Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC
2018 CARILION NURSING RESEARCH CONFERENCE
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CONFERENCE SUMMARY 178 Registered Attendees 22 Poster Presenters 15 Podium/Panel Presenters
11 Vendors 1 Keynote Speaker
Record number of attendees!
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Keynote Stephanie Ferguson, PhD, RN, FAAN Role World Health Organization (WHO) Consultant and Facilitator; University of Lynchburg Professor of Nursing Presentation AM: Global Health is Everyone’s Health
PM: So, Here’s How You Get There!
Keynote Speaker
l-r: Kim Carter, PhD, RN, NEA-BC; Stephanie Ferguson, PhD, RN, FAAN; Seyi White, ADN, RN; Brandie Bailey, MSN, RN, NEA-BC
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Oh, The Places We Have Gone! Panel Presentation
Panel from l-r: Jennifer Bath, MSN, RN, AGCNS-BC, CEN, TCRN (Trauma Services) Sara Wohlford, MPH, RN (Efficiency & Sustainability) Phyllis Whitehead, PhD, APRN, ACHPN, RN-BC (Palliative Care) Kim Bolling, BSN, RN, CCRN (Transfer Center/CSICU) Mel Morris, MSN, RN, CMTE (CMC Patient Placement) Cathy Jennings, DNP, RN, ACNS-BC (CVI-Surgery - Moderator) “Oh the places you’ll go, Today is your day! Your mountain is waiting, So.....get on your way! ~ Dr. Seuss
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Poster Presentations
Integrating Technology: Creating reform at the state board of nursing level to implement organizational change for PICC Tip Confirmation. Fran Conklin, BSN, RN-BC, CRNI, VA-BC - Centra Health - Oncology
Health Analytics Research Team – Love Your Research! Mattie Tenzer, MS - Director, Carilion Health Analytics
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CLEAR Model (Carilion Nurses Leading Excellence through Active Research). Louann Janney, RTR, RCIS – Cardiac Cath Lab & Nursing Research Council
The Implementation of the essential competencies for evidence-based practice in baccalaureate nursing education Elizabeth Whorley, PhD, RN, CNE - Assistant Nursing Professor, Liberty University
Research is our SuperpowerClinical research nurse/ coordinator role in the research process. Vivian Wilson, BSN, RN, CCRP – Research & Development
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Poster Presentations
When You Need to Vent: Ventilator associated pneumonia prevention in the emergency department. Lisa Girani, BSN, RN; Ashley Allen, BSN, RN; Jon Behnisch, BSN, RN; Kris Peters, MSN, RN; Stephanie Hodges, BSN, RN; Donna Bond, DNP, RN, CCNS, AE-C, CTTS – CRMH Emergency Dept & Nursing Quality and Safety
Carilion Health Sciences Library. Mary Catherine Santoro, MLS Librarian
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The use of an early warning system to improve patient outcomes. Brandie Bailey, MSN, RN, NEA-BC; John Hudson, PhD, RN, NEA-BC; Kim Carter, PhD, RN, NEA-BC – CRMH Resource Pool, Nursing Research, Old Dominion University – Adjunct Instructional Faculty, Nursing.
I Got the Money! Key strategies to secure grant funding for research & EBP. Rebecca Clark, PhD, RN & Kim Carter, PhD, RN, NEA-BC – Nursing Research
Staff education and sequential compression device use in procedural areas. Joanna Maas, ADN, RN – Carilion Endoscopy
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Poster Presentations
Back to Basics: Reducing CAUTIs in an ICU Suzanne Beels, MSN, RN, CCRN & Susan Blankenship, MS, BSN, RN, PCCN – CRMH VICU & Human Resources Clinical Staff Teaching
Leading in Virginia: Advance care planning, a patient centered approach. Caroline Butt, BSN, RN & Mary Collette Carver, DNP, APRN, FNPBC, NEA-BC – Carilion Clinic Family and Community Medicine
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“Things may happen and often do to people as brainy and footsy as you” ― Dr. Seuss, Oh, The Places You'll Go!
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Carilion Clinic Nursing Research CONFERENCE ABSTRACTS November 8, 2018
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The use of an early warning system to improve outcomes Brandie Bailey, MSN, RN, NEA-BC - Nursing Resource Pool; John Judson, PhD, RN, NEA-BC Old Dominion University – Adjunct Instructional Faculty; Kim Carter, PhD, RN, NEA-BC - Nursing Research Failure to Rescue (FTR) is defined as the failure to identify complications. Medical errors and FTR events are responsible for 60,000 deaths per year and approximately $6.9 billion in excess healthcare costs between 2005 and 2007. Many patient deaths are preventable (AHRQ, 2017). Nursing leadership is challenged to meet regulations and requirements from accreditation agencies related to patient safety and outcomes. Bedside nurses struggle to meet patient needs with the growing list of tasks, the increasing nursing shortage and higher nurse to patient ratios. Early warning systems offer an innovative solution to assist healthcare providers with early detection of subtle changes in order to prevent clinical deterioration. The purpose of this research is to determine whether the implementation of an early warning system will improve outcomes by early identification, escalation and treatment of clinical deterioration thereby preventing “failure to rescue” events. This project will determine the following: Is there a difference in the mean rate of ICU recidivism after the intervention compared to before the intervention? Is there a difference in the mean rate of ICU Length of Stay (LOS) after the intervention compared to before the intervention? Is there a difference in the mean rate of LOS after the intervention compared to before the intervention? Is there a difference in the mean rate of Non-ICU code blue events after the intervention compared to before the intervention? Is there a difference in the mean rate of mortality after the intervention compared to before the intervention? The intervention will take place in a large acute care facility, Magnet® designated academic institution (Carilion Clinic, 2017). The population will include adult (over 18) acute care patients in the inpatient setting. Patients under the age of 18 and over 89 years of age will be excluded. This will be a retrospective quasi-experimental pre/post implementation design. Pre-intervention data will be collected as a baseline. Post-intervention data will be collected to determine the effect on the outcomes related to the intervention. The effectiveness of the early warning system will be determined by the change in mortality rates, length of stay, ICU recidivism and number of code blue events outside the ICU environment. This project tests the implementation of the Peratrend™ early warning system and its effect on specific hospital and patient outcomes. This study hopes to establish best practice for patient safety, improve inter-professional collaboration, provide an innovative solution to predicting clinical deterioration and reduce healthcare costs. References Agency for Healthcare Research and Quality (AHRQ). (2017). Failure to rescue. Retrieved from https://psnet.ahrq.gov/primers/primer/38/failure-to-rescue Carilion Clinic (2017). Retrieved from www.carilionclinic.org
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Back to Basics: Decreasing CAUTIs in an ICU Susan Blankenship, MS, BSN, RN, PCCN - HR Clinical Staff Teaching; Suzanne Beels, MSN, RN, CCRN - 6M VICU Introduction/Background Catheter associated urinary tract infection (CAUTI) is the most common site of healthcareassociated infection – accounting for more than 30% of all HAIs reported by acute care hospitals. How would a critical care unit decrease an already high number of catheter infections? The decrease came from going back to the basics. Critical care nurses at a large teaching facility were able to reduce CAUTI related infections in the Vascular Intensive Care Unit from 14 in 2015 to only 3 in 2016. Drain days were decreased from 2162 in 2015 to 1929 in 2016. Standardized Infection Rate (SIRS) decreased from 2.5 in 2015 to 0.6 in 2016. This major shift in nursing practice came from collaboration with infection control, education, leadership and bedside staff. Policies were changed to empower nurses. Awareness was promoted through multiple innovative educational techniques with support from infection control specialists, unit preceptors, clinical team leaders, and clinical educators. Monitoring was performed by bedside staff as well as leadership. Patients were empowered and educated through use of technology. The ICU became part of a research project to determine a new use and practice for CUROS caps. Best of all, the nurses celebrated our success-keep it on front burner. PICOT Question P: Patients in VICU with urethral catheter I: Education of VICU RNs C: Previous CAUTI numbers O: The goal of this initiative was to improve patient outcomes by decreasing the amount of catheter associated urinary tract infections in an ICU by 50% over the next calendar year. The intent was to engage staff by increasing awareness and knowledge using multi-faceted and innovative approaches. T: 1 year Q: How do we use education to improve CAUTI SIRS rate? Methods - DMAIC Between 15-25% of hospitalized patients receive urinary catheters during their hospitalization. An estimated 13,000 deaths are attributed to urinary tract infections annually in the U.S. This ICU’s annual SIRs rate was double the national average over the past four years. A transformation in practice would be needed to out-perform national averages and align with hospital and national goals. To accomplish this goal, clinical nurses identified a need to go back to basics. Findings/Results Critical care nurses reduced the CAUTI related Standardized Infection Rate (SIRS) from 2.5 in 2015 to 0.6 in 2016.
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Discussion/Conclusions The Vascular Education Committee was charged with identifying potential obstacles and solutions to reducing CAUTIs by 50%. A needs assessment completed by clinical nurses identified barriers to success such as a knowledge deficit and time management concerns. The team developed education presented during an annual retreat with a skills stations focused on basic hygiene and catheter care. It seemed counter-intuitive to teach highly-trained critical care nurses something so basic. To engage skilled nurses, interactive simulation and teach back methods were used, emphasizing the overall impact of a CAUTI, the evidence-based policy, and bundle documentation. Staff commitment and buy-in was created. To perpetuate the change in practice, CAUTI prevention remained a priority, with the ICU participating in a quality improvement project, daily rounding, leadership rounding and reinforcement, development of infection control day, and other tactics to support ongoing success. Nursing implications Retreat evaluations cited the Back to Basics skills stations were the most beneficial part of the day. Increasing knowledge of the staff led to a decrease in CAUTIs from 14 in 2015 to 3 in 2016. Over the same timeframe, drain days were decreased from 2162 to 1929 and SIRs rate decreased from 2.5 to 0.6. Staff were recognized for their success and have committed to a goal of zero CAUTIs this year. CAUTI prevention improves patient satisfaction and outcomes by decreasing mortality, length of stay, and preventing hospital readmissions. Meeting national goals yields improved reimbursement without unnecessary expenditures. Nurses have shown great pride and accountability for their practice.
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Postoperative outcomes in vascular surgery patients who received nonautologous implants with and without intraoperative surgical site antibiotics (ISSA) Cheryl Bennett, MSN, RN, CNOR - Vascular OR; Karen Kline, BSN, RN, CNOR - Vascular OR; James Drougas, MD - Jefferson Surgical Clinic; Cathy Jennings, DNP, RN, ACNS-BC (Mentor) 2017 Nursing Research Fellowship Surgical site infections (SSI) account for approximately one-fifth of all hospital acquired infections (HAI)1. For the postoperative patient, an SSI can have significant personal, functional, and financial impacts1,2. The purpose of this retrospective data review was to determine the incidence of 3 postoperative outcomes: surgical site infection (SSI; defined as an infection within 30 days postoperatively), surgical wound variance (SWV, defined as a wound “other than normal or as expected”), and all-cause readmission rate (RR; occurring within 30 days of hospital discharge) in vascular surgical patients who receive non-autologous implants with ISSA and those who did not. This IRB approved research study included a convenience sample of surgical encounters from one surgical provider group, composed of a total of 456 surgical encounters when non-autologous implants were used: 248 with ISSA and 195 without ISSA, in calendar years 20132014. Descriptive and demographic data were abstracted from 2 sources for each surgical encounter: (1) the hospital electronic medical record (EMR), and (2) from the provider office EMR (post-discharge follow-up). The data were then compared for differences between the groups in 3 outcomes: incidence of SSI and SWV 30 days postoperatively and all-cause RR 30 days post-hospital discharge. No statistically significant differences in surgical site infection between the ISSA and no-ISSA encounter groups were identified, although more surgical encounters in which ISSA was used included an SSI (12 [4.84%] versus 5[2.56%]). Similar findings were seen with SWV: no difference between groups was found, although more surgical encounters in which ISSA was used included a SWV (35 [14.11%] versus 21 [10.77%]). A difference was found, however, between the groups in all-cause readmission rate (p=0.0282). A total of 34 surgical encounters (13.71%) in which ISSA was used included a readmission for any cause, whereas 14 encounters (7.18%) without use of ISSA included a readmission. Surgical encounters with ISSA resulted in longer hospital lengths of stay (1.3 more days, p=0.0382), fewer discharges to home with self-care (77% versus 84.6%), more use of home health services (13.31% versus 7.18%) and slightly more discharges to a rehab/other care facility (8.87% versus 8.21%). Although not statistically significant (p=0.216), more SSI’s occurred in encounters in which ISSA was used and more SWVs occurred in encounters in which ISSA was used (p=0.2931), two clinically significant findings. More all-cause readmissions occurred in ISSA encounters (p=0.0282). In addition, encounters that included ISSA more often required longer lengths of stay (p=0.0382), and more often required home health services or higher level of care post-discharge. There are relevant Nursing implications in the use of intraoperative surgical site antibiotics in this patient population. The RN, being a patient advocate, should encourage discussion among surgical team members regarding appropriate uses of ISSA for each individual patient
References
McHugh, SM (2011). The role of topical antibiotics used as prophylaxis in surgical site infection prevention. Journal of Antimicrobial Therapy, 6, 693-701. Barnes S, Spencer M, Graham D, & Johnson HB. (2014). Surgical wound irrigation: A call for evidence-based standardization of practice. AJIC: American Journal of Infection Control, 42:5, 525-529.
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Impact of a dysphagia, severity, and decision making algorithm on length of hospital stay, restraint use and cost in stroke patients Lindsay Collins, MSN, RN, CEN - Patient Care Managers; Barbara Boggs, MSN, RN, CCRN Nursing Resource Pool; Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC (Mentor) 2017 Nursing Research Fellowship Enteral feeding tubes, whether they are a nasally inserted tube (NGT) or a percutaneous endoscopic gastrostomy tube (PEG) are used to provide nutrition and hydration to stroke patients with dysphagia. For short-term feeding, the NGT could be appropriate, but for patients with severe dysphagia, a PEG should be considered early in treatment. A delay in a PEG consult and placement may lead to an increase number of nasally inserted tubes due to dislodgement, an increase in abdominal xrays, an increase in physical restraint use, an increase in hospital length of stay and an increase in patient cost. The aim of this study was to determine if the use of a Stroke and Dysphagia Severity Algorithm would improve patient outcomes by decreasing their length of stay, restraint use and cost. A retrospective chart review on stroke patients requiring feeding tubes due to dysphagia was conducted from August 14, 2016 through February 14, 2017. Data collected included dates when NGTs were inserted, number of tube reinsertions, number of abdominal xrays, dates of PEG consult and placement, restraint use, and length of stay. A Stroke and Dysphagia Algorithm was implemented on stroke patients requiring tube feeding due to dysphagia from August 14, 2017 through February 14, 2018 with same data collection. A T-Test was conducted on both sets of data.
A statistically significant difference was shown in the number of days to insertion of the nasal tubes with the number of days being greater in the pre-algorithm group, as well as the number of nasal tube replacements and abdominal xrays also greater in the pre-algorithm group. No statistically significance difference was shown between the two groups in restraint use or their length of stay; however, in both cases the difference could be clinically significant. Based on these outcomes, support from gastroenterologists and speech pathology was obtained to encourage early consult and placement of PEG tubes in order to improve the outcomes in this patient population.
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Leading in Virginia: Advance care planning, a patient-centered approach Mary Collette Carver, DNP, APRN, FNP-BC, NEA-BC - Ambulatory Nursing Practice; Caroline Butt, BSN, RN - Carilion Clinic Family & Community Medicine. Problem Despite the availability of reimbursement for Advance Care Planning (ACP) conversations, approximately 1% of Medicare beneficiaries participated in an ACP billable visit in 2016. Patients and families who do not have an opportunity to engage in a meaningful ACP conversation in the ambulatory setting, run the risk of not having their wishes honored when hospitalized. Patients and families are often involved in making end of life decisions during times of crisis in the acute setting. Purpose The purpose of this Quality Assurance/Quality Improvement (QA/QI) program was to improve ambulatory provider competence in conducting and billing for ACP conversations and to support the electronic filing of associated documents, which will allow clinical team members to honor patient decisions as defined in ACP documents. Objectives (1) Design and implement an ambulatory ACP training program. (2) Support the documentation of ACP conversations and subsequent billing. (3) Design and implement a standard document archival process to allow clinicians across the health system to easily access ACP documents. Methods Using Bandura’s Social Cognitive Theory as a framework, a comprehensive training program was designed to support the self-efficacy behaviors of ambulatory clinicians as they conducted, billed, and documented ACP conversations with patients. Chart reviews and billing reports were used to analyze the impact of the training on the number of new ACP documents filed each month and the billed ACP visits month over month. Outcomes This program designed and implemented a successful trainer and facilitator program for ambulatory clinicians working both inside and outside the health system. The ACP training program was approved and then adopted by the Virginia Department of Health (VDH) and Western Virginia Emergency Medical Services, logging over 100 workers trained across Virginia to date. Documented ACP conversations and billable visits improved by 49% in year two and by 114% in year three. A monthly monitoring system of all new ACP documents filed across the health system in the electronic medical record (EMR) are compared to the previous month to serve as a control measure for the program.
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Significance This program is a leading model in Virginia for training ambulatory clinicians in ACP conversations; it has demonstrated an increase in billable visits for the health system, and supports a consistent archival process for all ACP documents in the EMR. Care team members working across the health system are able to locate these important ACP documents; removing a significant barrier to delivering patient-centered care. The program demonstrated an improvement in conversations and after training, which supports the competence of the 68% of physicians who reported they lacked training (2). Finally, ambulatory nurses have served as leaders in this ACP training program and continue to conduct many ACP conversations under the supervision of primary care providers; demonstrating a quantifiable contribution for ambulatory nursing. References 1. Behavioral Sciences. 2017;7(18) Upstreaming and Normalizing Advance Care Planning Conversations – A Public Health Approach. 2. JAMA. 2016;316(17):1754. 10.1001/jama.2016.15577. Visualizing Health Policy. 3. Perry Undem Research Communication, November 2016. Conversation Starters: Research Insights from Clinicians and patients on Conversation About End-of-Life Care and Wishes
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Integrating technology: Creating reform at the state board of nursing level to implement organizational change for PICC Tip Confirmation Fran Concklin, BS, RN-BC, CRNI, VA-BC - Centra Health, Oncology Background When my vascular access team was researching use of ECG Doppler technology for PICC placements at our organization, it was identified that the Virginia State Board of Nursing (BON) has a "PICC Guidance Document" which stated that radiologic tip confirmation was required. Due to this requirement, the organization would not allow ECG Doppler technology to be used as confirmatory for PICC tip locations. Purpose To initiate change within the Virginia BON for the "PICC Guidance Document" as well as within our organization to allow nursing to confirm PICC tip confirmation with ECG Doppler technology. Project I petitioned the Virginia BON with a request for practice change to the "PICC Guidance Document�. Included with request was evidence based research articles supporting this technology as the "Gold Standard" for tip confirmation. The current procedure for PICC placement was explained as the board members were not familiar with the actual PICC procedure in today's practice. Results After making suggestions to the BON for changes to the PICC Guidance Document, then reviewing and revising these changes, the BON released new PICC Guidance allowing nurses in Virginia to incorporate use of ECG Doppler technology to determine PICC tip confirmation. Implications The above change was required before nurses at my organization were allowed to use this new technology for PICC confirmation. We were utilizing the technology as well as utilizing radiology readings which often were less accurate than the ECG Doppler or the image quality was poor and required additional radiologic films. Conclusions During the 1 year process of using ECG technology for PICC placements while waiting for the BON and organizational leadership to endorse use of ECG Doppler technology for PICCs, repeat x-ray films, exchange of PICCs, and re-positions have been requested based on radiologic data when the ECG doppler confirmation was obtained. With elimination of the x-ray, time, additional x-ray exposure & expense, will decrease and patient satisfaction will increase.
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Efficacy of intermittent heparin flush versus normal saline flush in adult implanted ports in prevention of catheter occlusions Stephanie Defilippis, BSN, RN - Oncology; Sunny Kook, MSN, RN-C - 7 West; Phyllis Whitehead, PhD, APRN, ACHPN, RN-BC (Mentor); Ava Porter, DNP, RN, CNE (JCHS-Mentor); Anne Cattigan, MSN, RN, OCN (Mentor) 2017 Nurisng Research Fellowship This study examined the use of intermittent heparin flushes of 50 units in implanted subcutaneous ports after each IV medication administration, compared to flushes with 10 milliliters of normal saline in the prevention of catheter occlusions requiring the use of alteplase. Study inclusion criteria were inpatient oncology unit admissions, 18 years of age and older, between October 2013 and May 2017, with an oncology/hematology diagnosis, and an accessed implanted subcutaneous port during their admission. Exclusion criteria included patients who had more than one central line (such as a peripherally inserted central catheter (PICC), flushes that were given off of the inpatient oncology unit, and continuous fluids ordered at time of the heparin flushes. This study was approved by the Institutional Review Board (IRB). A retrospective quasiexperimental 2-group comparison design was implemented (n=161 in each group) with data retrieval from the Epic electronic health record at Carilion Roanoke Memorial Hospital. From the data that were collected, the number of occlusions was extracted and the line orders were reviewed to see whether a trend in the number of occlusions differed with use of heparin versus normal saline flushes. Preliminary findings reveal that in the normal saline flushes where no heparin flushes were used at all, there were no occlusions. However there was one use of alteplase for a line that was difficult to flush and sluggish blood return. When heparin flushes were used, there were several instances where alteplase was administered. In these cases it was noted that the implanted subcutaneous port still flushed without difficulty; however, no blood was returned, so the alteplase was used. The samples of 480 encounters were reviewed to get 161 heparin flushes, and a total of 64 encounters were reviewed to get 168 normal saline flushes. Based upon our preliminary findings and the literature review, it appears that heparin flushes are not superior to normal saline flushes in prevention of catheter occlusion with implanted subcutaneous ports. Final data analysis is in process.
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The implementation of the essential competencies for evidence-based practice in baccalaureate nursing education Elizabeth Whorley, PhD, RN, CNE - Assistant Nursing Professor, Liberty University Integrating evidence-based practice into healthcare education has been a recommendation for the past 16 years. Despite this, barriers still exist with the utilization of evidence-based practice. The purpose of this study was to describe the current state of EBP scholarship in the curriculum of baccalaureate pre-licensure nursing programs. Essential Competencies for Evidence-Based Practice in Nursing (Stevens, 2009) was utilized to measure the state of EBP scholarship. The research question stated: how is evidence-based practice scholarship addressed within baccalaureate pre-licensure nursing programs? The research design was guided by Rogers’ diffusion of innovations theoretical framework and the star model of knowledge transformation Š. The study was a non-experimental descriptive design, and a convenience sample of n=96 surveys from program leaders was evaluated. The findings from this study fill an identified gap in nursing literature and show that EBP is addressed within baccalaureate pre-licensure nursing programs, described by the leaders in the programs. References Available upon request
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Assessing the correlation of nursing factors with likelihood of facility recommendation in inpatient experience surveys Hunter Sharp, MS - Health Analytics; Courtney Esposito, BS - Healthcare Analytics; Paul Garber, BBA, MBA - Administration; Brandon Jones, DNP, RN, NEA-BC - Administration; Jennifer Martin, DNP, RN, NEA-BC; - Quality & Informatics; Omid Shabestari, MD, PhD - Health Analytics One of the foremost drivers in healthcare initiatives has been the attempt to improve the quality of services they provide. One such approach prevalently used is Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys to identify opportunity areas from consumers point of view. CAHPS surveys are designed to understand patient perceptions and improve overall care by giving patients the ability to answer questions specific to their visit. Survey questions pertain to facilities and measure responses such as privacy of the individual, confidence of care, and staff collaboration. The likelihood of a patient recommending a facility is found on all CAHPS surveys. Understanding the relationship between recommendation and other nursing-related survey questions can enlighten possible opportunities for improving patient experience. Informing healthcare facilities of survey responses related to willingness to recommend could advocate the creation of initiatives to improve patient experience. A review of PubMed and CINAHL did not identify comparable evidence on nursing-specific measures. To identify questions that relate to patient recommendation, a correlational analysis was designed to determine what other survey questions in the nursing domain are correlated to facility recommendation. The analysis used survey results from inpatient medical facilities and obtained the correlation between patient recommendation of facility to other nursing-related survey questions. Nursing departments will be able to investigate what survey responses relate mostly to their given facility’s recommendation, and implement interventions accordingly. The data used in this study was obtained from Patient Experience Surveys conducted by an outside vendor. The correlational analysis, using a Kendall-Tau method, indicated that patient responses to the following are moderately correlated to facility recommendation: keeping patients well-informed, attention to patients’ personal needs, skills, attitude toward patients’ requests, friendliness, listening carefully to patients, treating patients with courtesy, and prompt response to call button in descending order. Each of these survey questions can be influenced by the care received from nurses during patient visits to an inpatient facility. The identified survey questions can be prescribed as areas that can affect overall perceived quality of care and facility recommendation. The results from this study can be used for prioritizing customized initiatives for improving patient experience at the unit level and elevating facility recommendations. With growing demand for facility level information, collaborative work with the health analytics department has led to the creation of near real-time dashboards that allow for monitoring the improvement on each of the above measures.
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The use of technology to decrease unplanned extubations Pam Flinchum, RT(R)(CT), ASN, RN - CCU; Kathleen Hayes, BSN, RN, CCRN - CCU; Donna Bond, DNP, RN, CCNS, AE-C, CTTS (Mentor) 2017 Nursing Research Fellowship Background Unplanned extubation (UE) is defined as the inadvertent removal of an endotracheal tube from a mechanically ventilated patient. This can be either intentional by the patient, or accidental when providing patient care. Adverse events related to UE include, but are not limited to the following: death, hemodynamic instability, respiratory distress, bronchospasm, laryngeal bleeding/edema, pneumonia, prolonged hospital stay, and increase cost. At Carilion Roanoke Memorial Hospital (CRMH) an average of 5-6 % of mechanically intubated patients have an UE. Literature confirms that most unplanned extubations are preventable.1-4 A recent literature review did not yield articles related to utilizing a computerized program combined with traditional weaning protocols to decrease UE. Study Purpose The purpose of this innovative project was to determine if improved communication during the mechanical ventilator weaning process between Respiratory Care Practitioners (RCP), Registered Nurses (RN), and providers will decrease unplanned extubations. The study question is, “Can the use of technology reduce the number of unplanned extubations?� The study objectives are: (1) Determine the current time frame from when the patient is ready to be extubated to the time of extubation, for both planned and unplanned extubations. (2) Implement a technological approach by utilizing EPIC to record to document times. Currently, there is no data on the time frames from when the patient is awake and able to be extubated to the time of actual extubation. The study used a quasi-experimental two-group nonequivalent comparison groups using pre/post intervention data. Our study population include mechanically intubated patients in the Coronary Care Unit (CCU), 9 South Medical Surgical Intensive Care Unit (MSICU), 10 Mountain Surgical Intensive Care Unit (SICU) and 8 Mountain Medical Intensive Care Unit (MICU). Method Our collection of data included a record review of patients (MRN, age, gender, race, diagnosis, length of stay (ventilator, unit & hospital), nursing unit, and an audit tool. The intervention involved using a data collection audit tool with information comprised of date/time provider notified that the patient was ready to be extubated. Findings A total of 334 control patients and 45 post-intervention patients with audit tool were included to address the study question. Demographics for the intervention group include: 21 females, 24 males; mean age 61.9, range 28-93 years of age; 38 White, 6 African American, 1 unknown; SICU -23 pts., MICU - 12 pts, CCU - 9 pts, MSICU -1 pt., Hospital length of stay 12.3 range 1-71 days. Patients in the post-intervention revealed that intubated patients are waiting an average of 3.5-4 hours from passing weaning parameters to the time of extubation. There was no significant time difference between the pre and post intervention groups. In addition, 22% of weaning parameters were not entered into the EMR.
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Implications for practice Potential impact with this study is reduction of unplanned extubations hospital wide, decreased ICU and hospital length of stay, decreased time on mechanical ventilation, and decreased patient complications related to unplanned extubations. Continued study in this area is recommended to answer the technological approach question. References 1. Jarachovic, M., Mason, M., & Kerber, K. (2011). The Role of Standardized Protocols in Unplanned Extubations in a Medical Intensive Care Unit. American Association of Critical Care Nurses, 20 (4), 304 -311. doi: 10.4037/ajcc2011334 2. McNett, M. & Kerber, K. (2015). Unplanned Extubations in the ICU: Risk Factors and Strategies for Reducing Adverse Events. The Journal of Clinical Outcomes Management, 22 (7), 303-311. 3. Silva, P.S., & Fonseca C. M. (2012). Unplanned Endotracheal Extubations in the Intensive Care Unit: Systematic Review, Critical Appraisal, and Evidence- Based Recommendations. Society of Critical Care Anesthesiologists,114 (5), 1003-1014. doi: 10.1213/ANE.0b013e1824b0296 4. Burns, S.M., Fisher, C., Tribble S., Lewis, R., Merrel, P., Conanway M.R., & Bleck, T. P. (2012). The Relationship of 26 Clinical Factors to Weaning Outcome. American Association of Critical- Care Nurses, 21 (1), 52-58. Doi: http://dx.doi.org/10.4037/ajcc2012425
L-r: Pam Flinchum, RT(R)(CT), ASN, RN; Linda Azen, RRT; Nikki Atkinson, MS, RRT; Katie Hayes, BSN, RN, CRRN; Donna Sink
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Characteristics and outcomes of heart failure patients who participate in cardiac rehab Renee Gerow, MSN, RN - CNRVMC Cardiopulmonary Rehab; Nancy Altice, DNP, RN, CCNS, ACNS-BC (Mentor) 2017 Nursing Research Fellowship Introduction/Background The Centers for Medicare and Medicaid Services (CMS) initiated Cardiac Rehab (CR) coverage for heart failure (HF) patients in 2014. Coverage is limited to HF patients who meet specific criteria. Carilion Clinic, a not-for-profit, integrated healthcare organization composed of seven hospitals in Virginia, has attempted to bridge a gap in service for this patient population by providing an 8 session free CR program. This program has been in existence for more than 10 years, and is accessible to all patients with a HF diagnosis. The aim of the 8 session free CR program for HF patients is to improve the health of this population and reduce readmissions. By providing monitored exercise sessions, education, and reinforcement of learned materials, patients are encouraged to become knowledgeable and responsible partners in their own healthcare. The 8-session program, which consists of rehab sessions twice weekly for one month, allows for early identification and intervention when problems present. PICOT question Does early attendance in Cardiac Rehab reduce readmission rates? Methods This IRB-approved study used a retrospective quasi-experimental comparison group design incorporating Epic Electronic Medical Record analysis for HF patients discharged between March 2013 and December 2017. Early CR attendance (within six weeks of discharge from the hospital) and readmission rates were evaluated in this study. HF patients who attended CR monitored, maintenance, and the free 8 session program were included. Certain patient characteristics were also evaluated for their impact on re-hospitalizations. The treatment group was identified as HF patients who had attended at least one CR visit within the first 6 weeks following discharge. The comparison group was identified as all HF patients who had not been admitted to the hospital during the previous one year period, were discharged to home/ self-care, and did not attend CR within six weeks of being discharged from the hospital. Thirty-day and 6week readmission rates were compared between the treatment and comparison groups. Findings/Results Out of 8,613 HF patients, 205 (2.4%) attended at least one session of CR within six weeks post discharge. Readmission rates for comparison group versus treatment group were: 2.7% versus 1.0% for 30-day readmission for HF (p=0.13); 14% versus 5.9% for 30-day all-cause readmission (p<0.01); 3.5% versus 1.0% for 6-week readmission for HF (p<0.05); 17% versus 7.7% for 6-week all-cause readmission (p<0.01). Multivariable Logistic Regression revealed that early CR attendance was associated with reduced 30-day all-cause and 6-week all-cause readmissions when adjusted for age, diagnosis of pulmonary disease, dialysis treatment, and Medicare insurance which were associated with increased readmission. Discussion/Conclusions Statistically significant study results support early access to CR in reducing re-hospitalization rates. Study limitations include unbalanced sample sizes which increased variance, potential bias due to exclusion of mortality outcomes, and operationalization of CR as attendance to only one session. Nursing Implications Current CMS criteria does not permit early access to CR and limits enrollment to a specific sub-group of this patient population. Future studies are needed with designs that further explore the impact of CR on HF readmissions.
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Ventilator associated pneumonia prevention in the emergency department and its effect on ventilator associated pneumonia rates in the inpatient setting Lisa Girani, BSN, RN; Ashley Allen, BSN, RN; Jon Behnisch, BSN, RN; Kris Peters, MSN, RN; Stephanie Hodges, BSN, RN - Emergency Services; Donna Bond, DNP, RN, CCNS, AE-C, CTTS - Advisor Ventilator Associated Pneumonia (VAP) is a pneumonia that develops when a patient is receiving mechanical ventilation. The presence of an artificial airway increases the chance of aspiration from the mouth into the lungs. Research on prevention of VAP has centered on the inpatient setting. However, the risk of VAP begins as soon as a patient is intubated. Intubation frequently occurs in the Emergency Department (ED) or even prior to admission to the Emergency Department. It is possible that the risk of VAP increases with increased ED length of stay, especially considering that many patients spend extended periods of time in the ED. Despite this, hospital policies and procedures do not address VAP and VAP prevention in the ED; rather, these policies and procedures focus on when a patient is moved to the inpatient bed. In order to obtain data on this issue, education was provided to ED staff on VAP prevention, including instruction on performing three elements of the VAP prevention bundle that include: tooth brushing, sub-glottal suctioning, and head of bed elevated 30 degrees. Staff was anonymously surveyed before, immediately following, and six months post education. Retrospective data was obtained from a 6 month period (10/1/2016 to 3/31/17) on all patients receiving mechanical ventilation in the ED. This included date and time of intubation/placement on mechanical ventilation, length of stay (LOS) in the ED, length of time on mechanical ventilation in the ED, and documentation of the identified three elements of VAP prevention. Following staff education and implementing these three VAP prevention elements, the same chart review was performed over a 6 month period (10/1/2017 to 3/31/2018) on patients receiving mechanical ventilation in the ED. The goals of this project are: to survey current knowledge of ED staff on VAP prevention, determine the effect of initiating VAP prevention practices in the ED, and to determine if patient LOS in the ED affects VAP and Infection-Related Ventilator Associated Complication (IVAC) rates in patients receiving mechanical ventilation in the Emergency Department. The overall goal is to decrease the number of patients who develop VAP and/or IVAC in the hospital. Data continues to be collected at this time, but will not be complete by the time of the research conference.
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Staff education and sequential compression device use in procedural areas Joanna Maas, ADN, RN - Endoscopy Venous thromboembolism (VTE) is a serious complication associated with procedural medicine such as endoscopy. Patients are subjected to the stress of surgery, dehydration due to pre-procedural fasting, and immobility due to anesthesia. These stressors contribute to a greater hypercoagulatory state and increased risk of VTE and its consequences including patient mortality, morbitites, and associated financial impacts. One method of VTE prevention is the use of sequential compression devices (SCDs) to prevent venous status. SCD efficacy is dependent on staff compliance with application and continuation of use. Current SCD policies regarding use do not specify use in off-unit procedures. Historically, SCDs have been used infrequently within the endoscopy department. An evidence-based practice project was conducted to determine whether education of staff would increase the rate of consideration of use of SCDs in cases estimated to be 60 minutes or more in duration. Staff were surveyed about their use of SCDs in this patient population. Staff then received education on VTEs and the importance of the use of SCDs in the department. Dedicated SCD machines were procured for use in the department. Staff was surveyed again 45 days posteducation to determine if there were changes in consideration of use. Staff consideration of SCD use increased from 14.3% to 58.8%. Factors in non-compliance include staff working in our outpatient department, with healthy patients, or not participating in the longer cases under consideration in the study. Staff education has had a clear impact on nursing care and contributes to the prevention of injury to our patients. Further action will include best practices for continued use of SCDs in procedural areas where procedures last â&#x2030;Ľ60 minutes in system-wide policy for the use of SCDs.
(Image credit: Kevin Parks, Krames Staywell)
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Advanced nurse training: Impact on trauma team attitudes and performance Kris Peters, MSN, RN; Ellen Harvey, DNP, RN, ACNS-BC, CCRN, TCRN, FCCM; Andrea Wright, MSN, RN, CEN, TCRN; Jennifer Bath, MSN, RN, AGCNS-BC, CEN, TCRN; Daniel Freeman, MSN, RN; Dr. Mark Hamill; Gary Meadows, MSN, MHA, RN, CEN, TCRN - Trauma Services The purpose of this study is to compare the impact of a registered nurse (RN) advanced trauma training program (ATCC) on trauma resuscitation team attitudes and performance compared to findings observed in prior interprofessional teamwork studies conducted in the same setting. This IRB approved prospective, quasi-experimental study was conducted in a Level 1 trauma center. Trauma ATCC-RNs (n=39), surgery (n=29) and emergency medicine residents (n=23) practicing during the study time period comprise the convenience sample. Trauma ATCC-RNs (n=39) completed self-confidence surveys. The Brief-Team-Perceptions-Questionnaire (Brief-TTPQ) was completed by ATCC-RNs (n=19) and residents (n=9) to measure perceptions of safety. Trained evaluators scored trauma resuscitation team performance using the validated Trauma-Team-Performance-Observation-Tool (TPOT). TPOT scores pre-ATCC (40-teams) were compared to 6-months (42-teams) and 12-months (39-teams) post-ATCC scores. Clinical efficiency data were gathered from the trauma registry during TPOT observation periods. Comparisons were analyzed using Chi square, t-tests and ANOVA. ATCC-RN selfconfidence in skills increased in all areas post-ATCC (p < 0.05). Differences in safety perceptions (Brief-T-TPQ) between and within ATCC-RN/resident groups overtime are insignificant (p > 0.05). Total TPOT team performance scores at 6-months postATCC training are significantly higher than pre-ATCC and 12-months post-ATCC (p=.0011). No statistical differences in trauma patient characteristics for age, gender, Injury-Severity-Score or Trauma-and-Injury-Severity-Score were noted between clinical efficiency study periods (pre-ATCC/n=260; 6-months post-ATCC/n=170; 12-months post-ATCC/n=220; p > 0.05). Efficiency gains in time in minutes to CT and ED dwell time seen in prior studies within the institution were not seen post-ATCC (p > 0.05); however time to ultrasonography 12-months post-ATCC is significantly shorter compared to pre and 6-months post-ATCC periods (p=0.0071). This study is the first to suggest ATCC for RNs may positively impact trauma RN confidence and team performance. Study findings suggest interprofessional trauma resuscitation team training provided every six months may support sustained improvement gains over time.
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Assessing palliative and end-of-life educational needs of registered nurses working with adult inpatients Johnathan Phillips, MSN, MSEd, RN-BC - Palliative Care The Palliative and Hospice Nursing Professional Issues Panel (The Panel), created by the American Nurses Association (ANA) and the Hospice and Palliative Nurses Association (HPNA), convened to determine nurses' roles that "promote health equity and improve access, safety, and quality of palliative care." The Panel concluded, "Seriously ill and injured patients, families, and communities should receive quality palliative care in all care settings. This is achieved by the delivery of primary palliative care nursing by every nurse, regardless of setting" (2016). Are nurses prepared for the charge? Schulman-Green, et al. (2011), identified the "need for additional education in both basic and discipline-specific activities related to palliative and end-of-life care." Lazenby, et al. (2012), found that 59 percent of nurses had basic end-of-life training but notes that their convenience sample drawn from professionals knowledgeable about palliative and end-of-life care limits the generalizability of their study. Moir, et al., (2015), discovered that nurses with less experience voice discomfort in communicating with patients and their families at the end-of-life. They concluded, "All nurses, across patient population areas, may benefit from end-of-life care education in order to increase their own skill and comfort in caring for these patients.â&#x20AC;? The primary objective of this study is to assess the palliative and end-of-life educational needs of Registered Nurses serving adult inpatients. Secondary objectives of this study are to determine if a relationship exists between palliative and end-of-life educational needs and the academic preparation of the nurses, to determine if a relationship exists between palliative and end-of-life educational needs and the years of experience of the nurses, and to determine if a relationship exists between palliative and end-of-life educational needs and the primary practice setting of the nurses. This study will use a quantitative, descriptive, non-experimental design. The study population will consist of a convenience sample of Registered Nurses whose primary work unit is an adult inpatient setting of a major teaching hospital in western Virginia. The online survey will be open for four weeks and take approximately ten minutes to complete. The results of the study will be shared at the conference and used to help to plan future educational offerings. A recent movement to include palliative and end-of-life care in healthcare reform is supported by various organizations. The American Heart Association/American Stroke Association "recognizes that palliative care helps meet the priority needs of patients, better aligns patient care with preferences, supports clinical care best practices, and contributes to improved quality of care and outcomes for patients and families" (2016). The National Quality Forum projected that palliative care programs in U.S. hospitals have grown by 125 percent in the last decade (2012). The Institute of Medicine (2015) recommended that healthcare delivery systems and medical centers "expand the knowledge base for all clinicians" regarding palliative care.
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Small Teeth, Big Problem: Pediatric toothbrushing and hospital acquired pneumonia Katherine Lilley, BSN, RN, CPN; Allison Walker, BSN, RN, CPN - Carilion Childrenâ&#x20AC;&#x2122;s Hospital; Donna Bond, DNP, RN, CCNS, AE-C, CTTS (Mentor); Lisa Allison-Jones, PhD, RN (JCHSMentor) 2017 Nursing Research Fellowship Hospital acquired pneumonia (HAP), including ventilator acquired pneumonia (VAP) and postoperative pneumonia (POP), contributes to increased length of stay, readmission, increased ventilator time, healthcare costs, and presumably decreased patient/family satisfaction (Davis & Finley, 2012; Esperatti et al., 2010; Quinn et al. 2014). This substantiates a need for higher level of awareness and proactive prevention by healthcare providers. In adult populations, oral care bundles have proven effective in preventing HAP, and poor oral health has been associated with HAP in elderly and institutionalized populations (Martin-Loeches, Ignacio & Torres, 2014; El-Solh, et al., 2004; Fuchshuber et al., 2012; Robertson & Carter, 2013; Quinn et al., 2014; Halm & Armola, 2009; Johnstone, Spence, & Koxiol-McClain, 2010). Preoperative toothbrushing has been shown to be effective in reducing postoperative pneumonia in the adult population (Akutsu et al., 2010; Burgan, Tura & Lamas, 2014; Martin-Loeches & Torres, 2014). Minimal research exists in the pediatric population concerning HAP, with the exception of some studies performed on oral care bundles for VAP.
This project used a retrospective pre and post intervention design to determine the incidence of HAP and the effect of preoperative and preprocedural toothbrushing compared to those patients who did not have the intervention on the incidence of HAP in surgical and procedural pediatric patients admitted to Carilion Roanoke Memorial Hospital. Given the data and population available, 100% of patients that fit criteria were used in study, therefore a power analysis was not warranted. Total sample size for study was 2637 patients (1312 pre/1325 post). In the postintervention group, 625 patients were documented to receive intervention of toothbrushing, identifying a problem with documentation. Descriptive statistical analysis was conducted on both pre- and postintervention groups and chart reviews were performed on patients diagnosed with pneumonia. The preintervention group had 4 pneumonia diagnoses and the postintervention group resulted in 3 pneumonia diagnoses. In the preintervention group, 3 pneumonias were present on admission. In postintervention group, 2 were discovered to be present on admission after chart review. The incidence of HAP in pediatrics is low. The average time between toothbrushing and procedure time was 1.5 hours, with the goal being under 1 hour at the start of the study. The intervention did not prove to be statistically significant in rate of HAP. A larger study with closer monitoring of documentation is potentially warranted to further evaluate the intervention. Implications for nursing are emphasis on daily care and emphasis on documenting interventions performed throughout the day.
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Additional Conference Attendance By Carilion Staff
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Reviewer: Angela Alderman, BSN, RN-NIC Unit: 14S NICU
Association of Vascular Access Conference September 16, 2018 Columbus, Ohio Session Title: Neonatal PICC Tip Location: Anatomy of a Lawsuit-Anatomy of a Death. Mistakes made - Lessons be learned Presenters: Ken Symington, MD - Interventional Radiologist, Inland Imaging Associates, Spokane, WA & John Brown, JD - Attorney, Georgia Infant Death, Augusta, GA
Session Highlights:
Discussed the evidenced based practice and research behind proper PICC tip placement Specifically discussed legal implications for providers that insert PICC lines Discussed current malpractice cases in NICU patients involving malpositioned lines. Defined proper placement guidelines Overview of vein and cardiac anatomy Spoke about the importance of placing the patient in the same position for xrays to determine line placement Spoke about timely xray readings for line placement
Take-away for Carilion: In the Neonatal patient, the PICC tip should reside in the Cavioatrial Junction which lies in the lower 1/3 of the SVC. Our institution must have proper training for chest x-ray interpretation for all providers including resident staff. It was recommended that we have a 30 minute turnaround time or live reads for images determining PICC tip or central line location. We need to insure that we have quality images to determine tip location. Most importantly we need to be able to visualize the PICC tip location at all times on all of the patients, not just at insertion. Make sure that your PICC insertion staff have ongoing education.
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Reviewer: Phyllis Whitehead, PhD, APRN, ACHPN, RN-BC Unit: Palliative Care
28th International Conference on Communication in Healthcare (ICCH) September 1- 4, 2018 Porto, Portugal
Session Title: In Pursuit of Patient Engagement: Challenges, Barriers and Breakthroughs Presenter - Meg Gaines, Director of the Center for Patient Partnership & Professor of Law, University of Wisconsin, Madison Session Highlights: I presented at the 2018 International Conference on Communication in Healthcare (ICCH) in Porto, Portugal. One of the plenary sessions addressed patient engagement. This session discussed the challenges of truly engaging patients especially how we can improve our communication with patients and their families. The speaker Meg Gaines, Director of the Center for Patient Partnerships and Professor of Law, University of Wisconsin, emphasized that we must include patients as we develop patient and family education and research. Patients most often are absent when we are making crucial decisions on what to research and teach. Patient voices are rarely heard and integrated into our teachings. Ms. Gaines challenged participants to re-examine how we design projects and educational programs by incorporating patientsâ&#x20AC;&#x2122; perspectives and ideas.
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Reviewer: Nancy Altice, DNP, RN, CCNS, ACNS-BC Unit: Cardiovascular Institute
2018 Virginia Nurses Association Innovations Conference September 21-22, 2018 Richmond, VA
Session Title: On the Road Again: Good Health and Great Hair! Kaiser Permanente, Baltimore, MD
Session Highlights: I attended the 2018 Virginia Nurses Association Innovations Conference in Richmond on September 21-22, 2018. One of my favorite sessions was titled, “On the Road Again: Good Health and Great Hair!” This breakout session was about a small team led by a nurse practitioner from Kaiser Permanente providing preventative care outreach to an underserved neighborhood in Baltimore. They had a mobile clinic housed in a large truck, but the people in the neighborhood were not accessing the services they had to offer. The team recognized that access was about more than just providing a service in a convenient location. They needed to overcome cultural barriers and suspicion about their motives in order to be accepted by the community. The team decided to partner with a barbershop and beauty salon in the neighborhood. They gained the trust of those who were providing hair styling services because they had relationships of trust with their customers in this community. The nurses got to know the people who came to these businesses and began by just offering flu shots inside these shops. The barbers and hairstylists offered some encouragement as well about the benefit of getting a flu shot. Once these connections were made, the nurses offered additional services if the customers wanted to come to the mobile health vehicle which was parked nearby. Their presentation about this community outreach project ended with this statement, “Innovation is moving outside of your comfort zone for the good of the mission.”
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Reviewer: Brandie Bailey, MSN, RN, NEA-BC Unit: Nursing Administration
2018 Virginia Organization of Nurse Executives and Leaders October 5, 2018 Williamsburg, VA
Session Title: Professonal Presence Presenter: Tonya Jones, MS, BA - Learning and Organizational Effectiveness Training Manager, Sentara Healthcare Session Highlights: I attended the VONEL conference (Virginia Organization of Nurse Executives and Leaders) in the fall to present my DNP Capstone Research. While much of the conference was spent by my poster, I did hear an inspirational speaker regarding executive presence. It was a quick reminder of how leaders can get lost in the day to day need for computers and cell phones and forget the human connection. Additionally, it was mentioned how leaders present themselves. Are they all business all the time? Or do they come in scrubs occasionally to help out their staff. Do they come in scrubs everyday with their hair wet and disheveled, unprepared to meet the day? Do they look like a leader? Take Away for Carilion: There was an abundance of representation from the eastern part of the state. It would be nice for Carilion and all our research and leadership projects to be recognized at the state level. The VONEL conference also had a strong presence of students from Sentara from nurse residency. This may be something we want to look into for those interested in future leadership roles?
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Reviewer: Stephanie Defilippis, BSN, RN Unit: 10S Oncology
2018 Virginia Nurses Association Innovations Conference September 21-22, 2018 Richmond, VA
Session Highlights: In September, I was able to go to the VNA Innovations Conference in Richmond, VA. At this conference, I learned about facilities that have designated a room/office in the building that staff may go to with visions of things they would like to develop to improve the care of their patients. Their creations may eventually be developed into inventions that will help make caring for our patients easier and more efficient. The designated creation room was stocked with various types of supplies that made it possible for the the nurses/ancillary staff to make their visions come true. There was a staff member monitoring the room to help the nurses/ ancillary staff think of additional supplies they would need to put their ideas together! This would be an exciting prospect to to research to see if it could be developed at Carilion.
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Reviewer: Kim Carter, PhD, RN, NEA-BC Unit: Nursing Research
Conference travel funded by a grant from Merck, Sharp & Dohme
28th International Conference on Communication in Healthcare (ICCH) September 1- 4, 2018 Porto, Portugal Session Title: In Pursuit of Patient Engagement: Challenges, Barriers and Breakthroughs Presenter - Meg Gaines, Director of the Center for Patient Partnership & Professor of Law, University of Wisconsin, Madison Session Highlights: Following a seriously and consistently flawed patient experience, Meg established The Center for Patient Partnerships at University of Wisconsin. Patients engaged with Schools of Law, Pharmacy, Medicine, & Nursing to improve outcomes through patient advocacy, education, service co-design, research, and policy advocacy. HERN (Health Experiences Research Network), established in 2014), is a network building a repository of EB patient experiences with specific aspects of health and health care. Adopted by researchers in 12 countries to date. HERN is: Partnership with patients (Patient voices in education) Interprofessional Quality Outcomes Focus on Health Community collaboration and engagement Healthtalk.org provides free, reliable information about health issues and real-life experiences for over 100 subjects. Hipxchange.org provides toolkits for research and practice. Communication…Listening…consulting…engaging…partnership Communication is facilitated by the Integration of theater and arts: improve, storytelling, art, music, and games. An example curriculum was shared that addresses depression and young adults in their own voices. This curriculum contains 3 hours of module-driven activities, plus 1 hour of debrief to explore stigma and empathy. The PowerPoint for this session is available at: https://www.each.eu/wp-content/ uploads/2018/09/Plenary-Meg-at-ICCH-2018.pdf
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Index Page Introduction - Mary Brewer, RDN, RN, MSN, MBA .....................................................................
1
2017 ANCC Magnet® Conference (i) Magnet® introduction ......................................................................................... (ii) Welcome to Denver, CO ................................................................................... (iii) Introducing our Magnet® Presenters ................................................................. (iv) Magnet® Session Highlights .............................................................................. (v) Magnet® Keynote Speakers .............................................................................. (vi) Magnet® Highlights............................................................................................. (vii) Magnet® 2019 Conference ................................................................................
2 4 5 6 14 16 17
2017 Carilion Nursing Research Conference (i) Conference Summary ........................................................................................ (ii) Keynote Speaker ............................................................................................... (iii) Panel Presenters ............................................................................................... (iv) Podium Presenters ............................................................................................ (v) Posters .............................................................................................................. (vi) Conference photos ............................................................................................ (vii) Conference abstracts .......................................................................................
19 20 21 22 26 31 32
Additional Conference Attendance (i) Conference reviews ............................................................................................
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Index ...........................................................................................................................................
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Carilion Nursing Editorial Board: Kimberly Carter, PhD, RN, Editor Margaret Perry, MSN, RN, Associate Editor Donna Goyer BS, RN, CPAN, CAPA Christine Huson, MSN, RN Deirdre O. Rea, MSN, RN Sarah Browning, DNP, RN Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC Vivian Wilson, BSN, RN, CCRP Candace Asbury, BSN, RN Desiree Beasley, MSN, RN, CCRN, CCNS Angelina Surgent, MSN, RN, ONC Monica Coles, MSN, RN-BC, ACNS-BC Michele Kosinski, DNP, MBA, RN James Ingrassia, MSN, RN Lisa Allison-Jones, PhD, MSN, RN Nancy Altice, DNP, RN, CCNS, ACNS-BC Ann Beheler, ADN, RN Cat Brandon, RN Sarah Dooley, MPH, BSN, RN Shanna Flowers, MA Cindy W. Hodges, RNC, BSHS, FCN
HART: Carilion Health Analytics Research Team
Provides consultative services to further research, QA/QI and grants of Carilion Clinic and our collaborative partners Supports data management & biostatistical services Provides data extraction, merging and EPIC research builds and billing REDCap (Research Electronic Data Capture) Clients include physicians, nurses, clinicians, fellows, residents, JCHS, VTSCOM VTCRI, VT, Radford University Open Office Hours: CRMH 1S Old CTAC space - Mon & Wed 9am-5pm Riverside 3, Conf Room 1B- Fridays 9am-5pm www.insidecarilionclinic.org/HART
EVENT & CONFERENCE REMINDERS: 2019 Carilion Clinic Research Day - April 9, 2019 (tentative) 2019 Week of the Nurse, Art & Science of Nursing Showcase - May 8, 2019 2019 Carilion Nursing Research Conference - November 7, 2019 (tentative) 2019 Virginia Patient Safety Summit, Richmond, VA - Jan 30-Feb 1, 2019 2019 VNA Spring Conference, Richmond, VA - April 17, 2019 (*Registration Deadline April 10, 2019) 2019 American Academy of Ambulatory Care Nursing (AAACN) 44th Annual Conference, Palm Springs, CA - May 8-11, 2019 2019 AMSN 28th Annual Conference, Hilton Chicago, Chicago, IL September 26-29, 2019 *Poster Abstracts due by 5/15/19, Speaker Abstracts due by 10/30/19. 2019 National ANCC Magnet Conference - Orlando, FL - October 10-12, 2019, Call for Abstracts CLOSED.