2021 Annual Conference

Capture Value of the CNS

Background: The Clinical Nurse specialist (CNS) role is novel in our country and the goal of this research project is to explore the perceptions that experienced, and highly specialized Registered Nurses (RN) have of the CNS role through description of the RNs’ experiences, thus facilitating the transfer of the CNS role locally. Methods: Interviews were conducted with six RNs (two managers, one CNO, two educators, and one clinician) and thirty-two RNs participated in five focus groups. Participants were purposively sampled from Intensive Care Units (ICU) and Emergency Departments (ED) from four public and private hospitals. The analysis of the narratives and field notes utilized thematic content analysis. Outcomes: Common aspects of the CNS competencies and the experienced RN were recognized. These include: direct patient care, assessment, and mentoring, with important differences in management, research, and coaching competencies. Implications: Findings could facilitate the development of a master’s program for the CNS in Chile. The intent is to search for ways to offer formal recognition of experienced RNs’ skills and clinical experience thus motivating their interest for attaining the master’s degree program.

CNS Improving Outcomes
Capture Value of the CNS
Other

Bridging the gap from nursing school to inpatient care of critically ill patient is a major challenge facing new graduate nurses. With the use of clinical orientation pathways, use of the 'clinical instructor model' the new graduate nurses successfully transition from novice nurses to advanced beginners and then competent nurses over three phases of the clinical pathway program for critical care. This program will outline the development, implementation and successful use of these pathways in a community hospital setting.

Capture Value of the CNS

The Clinical Nurse Specialist role is often misunderstood in terms of value added. Role confusion and the need for innovative methods of identifying value are examples of barriers for the development and growth of the role within organizations. Once the value added and role of the CNS are understood, overwhelming needs for the role within an organization and healthcare become evident. Literature reviews identify strategies in identifying value in the CNS role, but these are not always applicable due to the flexibility of the role. The aim of this work is to clearly articulate the value of the role within the organization and share the information with key stakeholders at all levels.

The Pediatric Intensive Care Unit integrated the CNS role with a vision to improve patient outcomes. Implementation of the role not only impacted patient outcomes, but also proved to reduce waste, foster a culture of safety, empower staff, embrace change, and implement evidence-based practices. Direct and indirect forms of value added can be utilized to acknowledge the work of the CNS role. A tracking process allows for articulate dissemination of the value added that can be shared with patients and families, bedside staff, and organizational leadership. Showcasing this summary of work from a financial and outcomes perspective is crucial in education and awareness throughout the organization at all levels, which then can lead to the resurgence of the role throughout healthcare. Innovative strategies used to identify and demonstrate value of the role can be translated into other organizations and other patient populations.

CNS Improving Outcomes
CNS as Project Manager
Capture Value of the CNS

Nurse onboarding process can be costly, long and complex. The purpose of this presentation is to describe the methods used by a CNS to improve the RN onboarding process.  The role of the CNS in project management to make hospital wide improvements will be discussed.

CNS Improving Outcomes

Background: 

Literature shows successful nursing orientation is key to nursing retention. Unsuccessful orientation cost approximately 1-1.5 time the employee’s salary, however the rate of successful orientations increases when nurses are provided orientation pathways. In two outpatient oncology services, the Clinical Nurse Specialist (CNS) noted extremely variables orientations occurring and no standard pathway.

 

Intervention:

Using the literature, an orientation pathway and preceptor guide for new outpatient nurses was implemented. The pathway includes an overview of orientation, preceptor and orientee expectations, weekly goals and readings, observations and classes. Each week, goals became more complex, growing upon previously developed skills. Routine check-ins are done with the CNS, Nurse Manager and Nurse Educator. The CNS educated preceptors on the appropriate use of the pathway and reviewed it with the orientee during week one of orientation. 

 

Outcome:

Nurses who completed orientation two years prior to implementation (n=5) and those who used the pathway (n=7) were surveyed on their satisfaction with orientation and preparation to practice. Preliminary data shows a medium-large effect size for readiness to work independently and satisfaction with readings. Those who used the pathway reported improved disease understanding, satisfaction with observations and weekly goals. Final presentation will include pathway, goals and data outcomes.

 

Conclusions/Implications:

Literature consistently shows that successful orientations positively correlates with nurse retention. Providing a disease-specific pathway with weekly goals and check-ins increases satisfaction and readiness to practice. CNSs have a role in establishing these learning environments and can use pathways to provide structure and support for new nurses.

Capture Value of the CNS
Other

At a Midwest academic health system, the CNS program was ending even though the hospital was growing rapidly and the need for CNSs was subsequently increasing. In order to recruit CNS students and create a pipeline into the organization, a novel CNS Internship was created and the position was filled by a CNS student in the final year of study. At the conclusion of this session, the learner will gain information on how the CNS Intern position was evaluated, and if it was successful for the organization.

Other

Using the Relationship-based Care model was a successful approach to support the Clinical Nurse Specialist in the onboarding process. Program strategies included assigning a formal preceptor, implementing evidence-based CNS competencies, leveraging Office 365 applications for an integrative approach to the orientation process, and designing a formal mentor role for post orientation support. Participants will come away with concrete examples of a CNS onboarding and mentoring program in order to implement a succesful program at their organization.

Capture Value of the CNS

The NIH is the nation’s largest research facility devoted to clinical research. At the NIH Clinical Center, the CNS spheres of impact is embedded into the NIH nursing department‘s mission: to provide clinical care for patients participating in clinical research studies within the intramural research program. As an integral team member, the CNS ensures the use of evidence-based decision-making and provides support for safe quality patient care through the design, coordination, implementation, and dissemination of clinical research. This is the unique mission of the CNS at the NIH.

In effort to further align expert skills, knowledge, and specialties of the CNS in a research environment, practice gaps were identified and resulted in an increase in patient safety and quality consultations, collaboration, and visibility on nursing and Clinical Center initiatives.  

Over a period of two years, the vision of the CNO in redefining the role led to the resurgence of the position, securing the recognition of the CNS as an advanced practice nurse. This resulted in the successful recruitment of hard to fill CNS positions, organizational visibility, and recognition of the CNS as a practice expert leading to the development of the CNS Practice Model in a clinical research setting.

Capture Value of the CNS

Shaping the Resurgence – Onboarding Coordinator and Structured Orientation Program Support CNS Transition into Practice

In order for Clinical Nurse Specialists (CNS) to resurge, a strategic plan is needed for transitioning new CNSs from academic programs to practice settings.  Historically at our institution a disparity existed in how CNSs were onboarded.  Orientations were individually planned by varying preceptors and ad hoc experiences were scheduled. A robust recruitment effort led to a rise in unexperienced CNS hires and further reinforced the need for a structured, cohort-based and consistent approach to onboarding. Envisioning and actualizing a strategic approach to onboarding captured the value of the CNS as a mentor and preceptor to those new to the role.   

A tenured CNS was appointed to be the onboarding coordinator.  The coordinator defines orientation experiences, evaluates orientee progress and mentors preceptors.  A 12-week orientation template and weekly goals routed in the CNS core competencies was created. To efficiently provide consistent information to all newly hired CNSs, a 16-hour didactic program was created. Taught by CNSs and interdisciplinary content experts, curriculum includes the CNS role in evidence-based practice, staff development and shared governance.  Content also focuses on nurse sensitive indicators and outcome measurement. This format allows for information to be shared with a cohort of peers versus individually in multiple sessions. 

Four cohorts, inclusive of 15 CNSs, have been held over the last 2 years. Preliminary data shows a reduction in variation among orientation blueprints, more efficient onboarding, increased in-role success and reduced human time and effort spent on orientation activities.  Final presentation will include review of outcome data and full program curriculum.

To recruit CNSs into the role, organizations must have methods to ensure CNSs feel supported and prepared for their role. Our structured orientation program led by an onboarding coordinator has successfully facilitated CNS transition to practice and exists as a recruitment tool also. Additionally, the role of onboarding coordinator provided a new career opportunity for a tenured CNS and demonstrated new value to supporting the ongoing growth of the profession.  Creating this type of program has allowed for successful mentorship of orientees and novice preceptors.  Other organizations looking to successfully grown their CNS program could use similar methodology.

CNS Improving Outcomes
Capture Value of the CNS
Interprofessional Collaboration

The onset of the Covid-19 pandemic resulted in reallocation of the CNS team as bedside nurses. Practicing side-by-side with clinicians highlighted needs for expert resources at the microsystem level. After resuming the CNS role, the team restructured its rounding process from a siloed method to a collaborative effort of enhancing visibility while maintaining focus on quality care and outcomes. Using the hospital’s predictive analytics tool as a catalyst, the CNS rounds on identified patients, making recommendations for care. Simultaneously, the CNS ensures best practices are in place to prevent hospital-acquired conditions. The team leveraged technology for efficient, focused data collection.

Utilizing dashboards created within the electronic application, the team quantifies time spent on nursing units and the interventions initiated for enhanced patient care and safety. Additionally, the team conducts ongoing monitoring of nurse-sensitive indicators influenced by the rounding process. Finally, data retrieved from the predictive analytics system allows the team to determine if the interventions put into place affect patient deterioration and prevent failure to rescue.

The revised rounding process brings clinical expertise to the bedside, guiding development of critical thinking and supporting interdisciplinary collaboration. Utilizing bidirectional communication between the CNS and bedside clinician enhances relationships and promotes positive patient outcomes. While the revised process is relatively new, the team continues to monitor improvement in nurse-sensitive indicators addressed during rounds such as central line and urinary catheter associated infections, hospital-acquired pressure injuries, aspiration pneumonia and falls.

Using structured processes while rounding at the patient bedside promotes critical thinking, enhances patient outcomes, and highlights the value of the clinical nurse specialist as a change agent. Staff appreciate the visibility of the CNS as an expert resource and the organization sees the worth through ongoing impact in quality outcomes.

Capture Value of the CNS

Significance & Background
A long-established ONN program existed in a National Cancer Institute designated Comprehensive Cancer Center (NCICCC) but lacked structure and defined outcomes as a navigation program. Practice depended on the setting, local needs, and physician demands. A common set of core competencies and baseline performance was needed for all ONNs regardless of specialty.

This multi-phase project was designed to evaluate the application of the 2017 ONN core competencies to build an evidence-based orientation model for novice ONNs in an NCICCC. Phase 1 involved assessing current-state role and job functions, reviewing the job description, developing competency measurement requirements, identifying learning opportunities from self-assessment, and developing ONN education.

Evaluation Methods
Incumbent ONNs were evaluated to ensure minimum qualifications were met. They provided input into operationalizing competencies for role delineation. Pre- and post-education self-assessments were utilized to identify learning opportunities and led to the development of learning plans and schema for an emerging ONN program. A two day multi-modal education course was developed to address competency areas collectively ranked weakly. Criteria for each competency were identified as a method of measurement.

Outcomes
Prior to intervention, ONNs scored themselves as Level Zero or One (limited experience and knowledge) for 19 of 40 competencies. Post education, only five competencies were rated Level One or less and the number of ONNs indicating an acceptable level of proficiency for each competency increased by 50% to 100%. All of the ONNs reported appreciation of the education course along with improved confidence and knowledge.

Implications
Utilizing nursing competencies is not new practice. However, developing an orientation program framework that allows ONNs to measure improved performance of required knowledge in their roles will have far reaching implications. Operationalizing the 2017 ONN competencies established baseline measurement requirements for ONN education. This framework will be utilized moving forward for novice ONN onboarding and professional development. The ONN core competencies guided the development of an evidence-based practice orientation framework and allowed standardization across disease specialty nursing practice. This orientation model prepares nurses with a variety of oncology experience and applies nursing competencies across the broad continuum of oncology care. This abstract will add to the literature relevant to the application of the ONS ONN competencies in development of an orientation program model.

 

 

Capture Value of the CNS

This presentation will discuss CNS role confusion, implications, and showcase some innovative methods to increase the visibility and highlight the value of the CNS in one large Healthcare system. Attendees will leave the session with ideas they can use at their facility or system.

Interprofessional Collaboration

Two Cardiac Clinical Nurse Specialists (CNS) in a two-community hospital system took on the challenge of changing the process for ordering and managing Wearable Defibrillators (WD) for the inpatient population.  Left ventricular dysfunction, or cardiomyopathy, is one of the most frequent causes of SCD.  Treatments for cardiomyopathy include an implantable defibrillator, however, not all patients immediately qualify, and therefore, WD is often prescribed for up to a period of ninety days.  By allowing patients to keep their WD on when admitted, it decreases the time to defibrillation, compared to traditional defibrillation, should it be needed.  In order to have successful implementation of the new processes, changes were made to the electronic medical record, WD order set, and reports were established.  Additionally, online and hands on learning were developed.  During the change process we found that the number of patients with WDs were much higher than previously known.  The CNSs were able to easily identify patients requiring WDs and were able to positively impact their plan of care. 

 

CNS Improving Outcomes
Quality Initiatives
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

     Tracheostomies are considered a low volume, high risk population, requiring a multidisciplinary collaborative approach. A multidisciplinary team within a Large Midwest hospital identified gaps in care being provided tracheostomy patients. These patients had increased complications, increased length of stay and delayed discharge readiness to home.  Through a formal care management focus with Clinical Nurse Specialists, a standardized rounding process was developed. CNS rounding three times per week provides advanced nursing support to both bedside nurses and patients. This process allowed the CNS to mentor bedside nurses in tracheostomy care.  One key strategy implemented was the use of a hand-held mirror to improve self-care and body image for patients with a new tracheostomy. Ongoing collaboration with home health care, speech and respiratory therapy to develop formal patient discharge education material including a hand-off tool from the hospital to home health care was also developed. 

     As a result of the standardized rounding was continuous positive feedback regarding perception of increased nursing confidence in management of complex tracheostomy.  Improved patient perception of trach self-care skills was realized through the use of the hand-held mirror. Patients had earlier decannulation rates, improved satisfaction and decreased complications.  HAPIs decreased from 5 to 1 as this process was fully implemented. The most significant improvement was an overall decrease in length of stay of more than 3 days. This results in a significant cost avoidance for the hospital. The CNS tracheostomy rounding has led to increased nursing comfort in caring for these patients as well as improved collaboration among all disciplines.  CNS driven care management including self-care and discharge readiness significantly decreased length of stay. Future efforts include the development of a CNS led trach clinic to provide out of hospital resources to this unique population between appointments to prevent risk of readmission.

CNS Improving Outcomes

Background

Clinical Nurse Specialists (CNS) are one of the most adaptable Advanced Practice Providers roles. CNSs are trained to be clinicians, educators, leaders, change agents, and researchers. CNS skills are used to influence practice and outcomes at the system, provider, and patient level. They bridge gaps between physicians, nurses, patients, and other allied health providers to improve patient safety.

Methods

In 2018, Ochsner’s innovative leaders recognized the value of the Clinical Nurse Specialist role and invested in a two-year pilot of a CNS who split responsibilities between facilitation of evidence-based practice and work as a critical care Advanced Practice Provider.

Results

A CNS-led resuscitation program resulted in a 65% decrease in codes outside ICU, 27% decrease in codes inside ICU, and a 4.7% decrease in admissions to ICU from inpatient beds. Cost savings are $600,000.  CNS-led inter-professional training included prevention of clinical deterioration, management of clinical emergencies, and central line training. The CNS trained over 1500 learners. The sessions led to discovery of patient safety breaches and opportunities to update and enhance clinical processes. The CNS coached 40 nurses through unit change projects within their units including burnout, noise, patient experience, sepsis, stroke, and clinical deterioration. Fiscal outcomes are $1000,000.

Conclusion

The Clinical Nurse Specialist is a unique advanced practice provider that can help develop, implement, and sustain successful  inter-professional patient safety programs at the system, unit, and patient level.

CNS Improving Outcomes

Typically, about 25% of hospitalized patients have a indwelling urinary catheter during their admission. The chance of a patient developing a catheter-associated urinary tract infection (CAUTI) ranges from 3-8% per day of catheterization. It has been shown that CAUTIs are the most common cause of healthcare acquired infections. Delay in urinary catheter removal and unnecessary usage places the patient at a greater risk of developing a CAUTI which in turns can led to increased costs, length of stay, mortality, and lack of reimbursement for the organization.

Chart reviews of patients with urinary catheters and rounding with nursing staff proved that a lack of knowledge existed in regards to the urinary catheter removal protocol, which was outdated. A decision to revamp the urinary catheter removal protocol and re-education among nursing staff was decided. A more evidence-based protocol was created after literature review. Appropriate indications were created that aligned with CDC guidelines to avoid unnecessary usage. Providing autonomy for nursing to make a decision to promptly remove a urinary catheter while caring for their patient was an important factor. Nursing have the ability to utilize their critical thinking skills to improve patient safety and outcomes.

The revised protocol was approved by a variety of committees and leadership. Dissemination will occur throughout the organization. Specific units will be targeted with re-education and rounding by the CNS. After the implementation, a decrease in the utilization of urinary catheters will be seen which should decrease the incidence of CAUTIs.

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives

 The purpose of this evidence-based practice project was to reduce CAUTI Standardized Infection Ratio (SIR) to meet the CMS value-based purchasing target of 0.75. The PICO question was: In the hospital setting, does the implementation of bedside staff CAUTI champions improve CAUTI SIR compared to no champions?

Although the hospital had implemented multiple evidence-based practices to reduce CAUTI SIRs, the quarterly SIRs for several years were consistently above 0.75. The hospital had not implemented bedside staff CAUTI Champions, a demonstrated evidence-based practice.

This project implemented the evidence-based practice of bedside staff CAUTI Champions, who, through education and support from the infection prevention team, became CAUTI experts. The champions conducted rounds on catheterized patients; provided immediate peer education when needed; validated staff competencies for indwelling urinary catheter insertion and maintenance; reported monthly CAUTI outcomes in huddles and staff meetings; advocated for best practices, and assisted in staff education of the standardized procedure for urinary catheter removal, CAUTI prevention patient education, and identification of alternatives to indwelling urinary catheters.

The CAUTI SIR decreased from 1.3 the quarter immediately before implementation, to 0.41, 0.4, and 0.23 in the three quarters post-implementation.  

Bedside staff CAUTI champions have been instrumental in infusing best practices on individual units through rounding on the maintenance bundle and advocating for best practices such as standardization of urinary catheter securement devices.

CNS Improving Outcomes

All nurses caring for patients who require cardiac monitoring with a diagnosis of STEMI or NSTEMI need to be knowledgeable about proper electrode placement and lead selection. This presentation will show how a CNS guided staff to change practice and to ensure patients were monitored in the appropriate ECG leads inorder to detect advanced arrhythmias, acute or silent ischemia and prolonged QT intervals.

CNS Improving Outcomes
Quality Initiatives

Title: Fall Prevention Clinical Decision Tool on an Adult, Medical-Surgical Unit

Significance and Background: Patient falls within a hospital setting are a prevalent safety problem. The Centers for Medicare and Medicaid Services have identified patient falls during hospitalization should never occur and are considered a hospital-acquired condition. Patient falls within a 31-bed, adult, medical-surgical, nursing unit have been increasing significantly within the past three years. This nursing unit experienced a 71% increase in patient falls within the first quarter of fiscal year 2018 and 2019 of patients hospitalized for medical and post-operative care following orthopaedic, general, colorectal, or podiatric surgeries; costing the hospital an additional $365,456.00 and a superfluous 163.8 hospital days per year.

Evaluation Methods: The Fall Prevention Clinical Decision Tool was developed as a guide for nursing staff in an acute care setting to identify patients at an increased risk of falling during their hospitalization. The content is based on the hospital’s current Fall Prevention Program strategies evidenced to reduce in-patient falls. The project data will include the AHRQ Ministry of Health Fall Prevention Knowledge test as the pre- and post-test, adherence rate of nursing staff to the Fall Prevention Program intervention, and the unit-based fall rate pre- and post-intervention.

Outcomes: Following Roger’s Theory of Diffusion framework, nightshift nursing staff adherence to the existing hospital Fall Prevention Program significantly increased. A total of 1,206 Fall Prevention Clinical Decision Tools have been collected during the 8-week implementation period. The tool was analyzed for nursing staff adherence to the existing Fall Prevention Program and unit-based patient falls rate. The unit-based fall rate decreased from 2.25 to 1.11 patient falls per 1,000 patient days.

Implications: Implementing a Fall Prevention Clinical Decision Tool is effective in heightening awareness of patient fall interventions within a medical-surgical nursing unit. The Fall Prevention Clinical Decision Tool guides nursing staff to correlate patients’ Morse Fall Scale score with the patients’ fall risk. The tool provides recommendations of which Fall Prevention Program interventions are appropriate to implement for patients that are identified as being at a low, moderate, or high risk of falling based on the patients’ Morse Fall Scale score. The Fall Prevention Clinical Decision Tool can be adapted to any Fall Prevention Program interventions and any clinical nursing practice culture.

Keywords: fall prevention, falls-acute care, fall prevention in hospitals, fall prevention checklist

CNS Improving Outcomes
Quality Initiatives

Significance and Background: Although the volume of central line infections in the ICUs is higher, non-ICU units have been found to have central lines in place for prolonged periods, with reported rates ranging from 2 to 6 per 1,000 lines days. In 2019, our facility experienced higher than expected CLABSI rates and SIR, 1.055, with similar trends of events occurring on non-ICU units. This supports the need for interventions to improve central line utilization and maintenance practices in non-ICU environments where infrequent exposure has not allowed for adoptions of best practices.
Evaluation Methods: Recruiting an engaged team of CNSs, CNLs, and infection preventionists, a standardized audit tool was developed which evaluated evidence-based recommendations for prevention including disinfection of hubs, needleless connectors, and injection ports before catheter access; use of chlorhexidine skin preparation for skin antisepsis; and routinely changing transparent dressings every 5 to 7 days and gauze dressings every 2 days or whenever soiled, loose, or damp. An electronic audit tool and dashboard were created to store audits, monitor for trends, and readily share findings. Collaboration with educators to develop educational materials and with leaders to coach identified teams occurred.
Outcomes: Identified opportunities include inconsistent labeling of IV lines with expiration dates, variable placement of alcohol-based port protectors, variability in CHG bathing, insertion of ports not allowing 360-degree coverage with a CHG protective disk, and accessing ports without provider order. Each opportunity was addressed with real-time education, formalized sharing of best practices, and dissemination of formal education to heighten awareness of policy. Coaching was provided to specific individuals identified as being inconsistent in caring for central lines per policy. While data is still being finalized, both rates and SIR are showing positive preliminary trends.
Implications: Standardized maintenance teams have been identified in the literature as pivotal in decreasing line-rounding subjectivity and variability. A small, dedicated team who is able to take ownership of CLABSI reduction can decrease unit and facility-level CLABSI rates, as well as reduce length of stay and cost. Furthermore, auditing, real-time education, and coaching are pivotal in creating a culture of awareness around the importance of CLABSI prevention. Success can also be attributed to having the support of dedicated masters prepared nurses in CNSs and CNLs.

CNS Improving Outcomes

Severe intraventricular hemorrhage (IVH) remains a major cause of death and a key indicator of a premature infant's short term and long term neurodevelopmental outcomes.  Annually, over 3600 new cases of severe IVH are reported with estimated costs of $53,600 per infant during initial hospitalization, and a lifetime care cost exceeding 3.6 Billion dollars. By utilizing an interdisciplinary care bundle to minimize the caregiver-imposed stress that increases a neonate’s risk for developing severe intraventricular hemorrhage (IVH), clinical staff in a level III NICU reduced the incidence of severe (grade 3 & 4) IVH in infants born at less than 30 weeks gestation by 71% in the first year following bundle implementation with an estimated cost savings of $643,200.  Grade 1 & 2 IVH rates were reduced by 13.9% in that same year.  Adoption of the IVH prevention care bundle and ongoing monitoring of staff compliance has contributed to sustained gains in IVH reduction for 5 years after bundle implementation and provided a pathway for permanent practice change.  Ongoing review of neonatal outcome data reported to the California Perinatal Quality Care Collaborative (CPQCC) has allowed clinicians to identify a distinct trend of severe IVH occurrence in severe intrauterine growth restricted infants (IUGR) greater than 30 weeks gestation.  The identification of this IVH occurrence trends, supported further refinement of the IVH care bundle to include birthweight quartiles and severe IUGR as criteria for inclusion in the IVH care bundle. 

CNS Improving Outcomes

Purpose: This process improvement project was implemented to decrease Central Line-Associated Bloodstream Infections (CLABSI) on SCVMC 4-East PCU Oncology Unit where patients are in extreme risk due to high central line utilization rate.

Relevance/ Significance: Central line–Associated Bloodstream Infections (CLABSI) result in thousands of deaths each year and billions of dollars in added cost to the US healthcare system, yet these infections are preventable. Patients with cancer are more vulnerable to infection because of impaired immune competence due to their disease process or chemotherapy-induced neutropenia. This infection can result in significant morbidity and mortality, prolonged hospitalization and increased costs.

Strategy and Implementation:  A review of the CLABSI cases identified gaps in practices to include failure to comply with CDC recommendations preventing infection during insertion and management of central lines leading to the development of an evidence-based CLABSI prevention bundle. Strategies included staff education on the appropriate indications, line assessment, 2-RN dressing maintenance, CHG bathing compliance, appropriate line access for patency, oral care, hygiene practices, 2-RN lab draw, patient empowerment and ensuring compliance through daily self-audit and Daily Management System. Staff education was provided using the Peer-to-Peer Knowledge Exchange (P²KE) Tool for a period of one month.

Evaluation/Outcomes:  71% percent reduction in total number of CLABSI from 7 in CY 2018 to 2 in 2019 and maintains at zero for 2020.

Implications for Practice: Prevention of CLABSI is a team effort involving all healthcare disciplines, patients and families. Nurses are at the center of person-centered care and are in the best position to assure that CLABSI prevention recommendations are incorporated into practice.

 

 

CNS Improving Outcomes
Pharmacology

Almost half of new diagnosed VTE cases occur during hospitalization.. At UKHC an in-depth review of PSI 12 cases for FY18, 19 and 20 was conducted.  Recurring themes identified in these audits were missed VTE chemoprophylaxis doses and generic “Hold” anticoagulation orders.  A multidisciplinary team implemented a suspend functionality for medication and eliminated generic “hold” orders. The total number of VTE cases decreased from FY18 and 19 decreased from a total number of 54 adn 51 to 39.  Cost avoideance numbers will be applied according to the facility determination of VTE costs per patient.

CNS Improving Outcomes

Contaminated blood cultures increase costs and potentially expose patients to unnecessary antibiotics. This places the patient at risk for complications such as C. difficile infections.

Current practices were reviewed compared to evidence based practices. An ongoing process improvement project for blood culture contamination reduction was implemented. Evidence based and best practices were implemented with ongoing evaluation against monthly blood culture contamination reports. The key intervention identified is the use of a plain red top waste tube cleaned with alcohol prior to blood culture draw.

The contamination rate went from greater than 3% to less than 2% overall, resulting in an approximate $300,000 cost avoidance.

Identifying processes to decrease blood culture contamination has been a long standing initiative in healthcare. In recent years there has been a focus on diverting the first 2-3 mL of blood using proprietary blood draw products that would have a significant increase in cost at approximately $10 plus per blood culture draw. Utilization of a plain red top tube and alcohol pad increases cost only by approximately 10 cents per blood culture draw. This new process has shown to significantly impact the reduction of blood culture contamination rates while being cost effective.

Role of CNS in COVID-19 Pandemic

The COVID-19 pandemic has created a need for quick development and implementation of rapidly evolving literature to improve patient outcomes.  In March 2020, literature appeared translating a technique formerly used for critical care ventilator patients with acute respiratory distress syndrome (ARDS) to awake, non-ventilated patients with acute hypoxemic failure due to COVID-19.  This session will describe the rapid development, implementation, and outcomes of a protocol in a large health care system.  In addition, the development of a national guideline will also be detailed.

Role of CNS in COVID-19 Pandemic
Other

This presentation will discuss resilience, the impact of lack of resiliency on individuals and organizations, and describe approaches which can be implemented to build resiliency in individuals as well as within an organization.

Role of CNS in COVID-19 Pandemic

The Role of the Clinical Nurse Specialist (CNS) requires adaptation to an ever-changing healthcare environment. At this NCI-designated Cancer Center our CNS team quickly responded to the Coronavirus Pandemic  via multimodal strategies with a variety of disciplines.  The CNS team stayed informed on the latest evidence-based practices and translated those into bedside care quickly and efficiently.   We will share how the CNS team modified work schedules to reach day and night nursing staff including those who only work weekends.  The team prepared and delivered multiple education and process change in-services, provided hands on demonstration of skills specific to COVID-19 nursing care, as well as infection prevention practices.  As a result our nursing staff has been able to care safely and confidently for COVID-19 patients and even more importantly protected our very fragile immunocompromised patient population.

CNS Improving Outcomes
Role of CNS in COVID-19 Pandemic
Capture Value of the CNS
Interprofessional Collaboration

Prone position therapy has been an evidence-based treatment recommendation for patients with moderate to severe Acute Respiratory Distress Syndrome (ARDS) for decades, and more recent studies support statistical significance in reducing mortality with the early initiation of prone positioning for greater than 12 hours per day (Guérin, 2013). Different techniques and equipment, for example the RotoProne® bed, exist to assist nurses in turning patient to the prone position.

Prior to March 2020, a community hosital Intensive Care Unit (ICU) had low volumes of patients needing prone positioning, utilizing this therapy via the RotoProne® only 3 times in 2019. With anticipation of a surge of patients with ARDS due to Covid-19, options for how to prone position patients was investigated. The supply of RotoProne® beds in central Indiana could not match the demand, causing delays of upward of 5-7 days. Delaying prone positioning greatly impacts effectiveness of the therapy. Implementation of manual prone positioning was needed to meet the needs of an ICU that grew from a capacity of 8 to 32 beds during the pandemic.

Methods: Intervention

The Clinical Nurse Specialist (CNS) reviewed guidelines, protocols and literature to develop criteria, prone preparation checklist and manual prone technique. This new manual prone process was vetted with the Intensivists and communicated to all ICU RNs, PCAs and Respiratory Therapists. After the CNS completed rapid experiments to determine best techniques to safely prone and reduce complications (i.e. pressure injuries, tube and line dislodgement), a quick 1-minute video was created and disseminated. Bedside coaching by the CNS and daily collaboration with the CNS, primary RN, RT and Intensivist focused on coordinating the patient’s plan of care to include prone therapy.    

Results: Impact and Significance

Data was collected on all patients with confirmed Covid-19 requiring mechanical ventilation (MV) admitted to the ICU from March 1 to June 30, 2020. Of the 55 total patients, 14 were manually prone positioned based on criteria met for moderate to severe ARDS for an average 3.5 days (range 1-10 days; median 3 days). Six of the 14 patients (43%) survived to discharge. Manual prone positioning was initiated on all 14 patients on day therapy was ordered. Three patients were over the recommended weight limit to manual prone position, and the RotoProne® was used with up to a 6-day delay on receiving the bed due to other hospitals’ demand. Four patients did experience mucosal membrane breakdown on the lip due to the Endotracheal tube, which is taped prior to prone positioning to ensure tube securement.  

Direct Cost Savings

Manual prone therapy was completed for a total of 50 days in Quarter 2, 2020. The RotoProne® bed rental cost is $1520 per day, equaling savings of $76,000. The only additional cost to manual prone positioning was each patient received a waffle mattress and cushion for skin protection and repositioning. This added approximately $60 per patient for a total of $840 for 14 patients. For 3 months, the direct cost savings from initiating manual prone positioning was $75,160.

Discussion

Rapid implementation of manual prone positioning during the Covid-19 pandemic ensured timely initiation of an evidence-based therapy. Without execution of this project, delays in prone therapy could have led to worsened patient outcomes and mortality. Next steps include formalizing the prone positioning guidelines and employing additional techniques to reduce prone complications. In the event of another Covid-19 surge, the ICU is prepared to meet the needs of patients with moderate to severe ARDS who need prone positioning.

Guérin, C., et al. (2013). Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine, 368(23), 2159-68.

CNS Improving Outcomes
Role of CNS in COVID-19 Pandemic
Patient Populations
Interprofessional Collaboration

• Title: CNS: Vital to the Team Developing an Innovative Way to Care for COVID-19+ Psychiatric Patients
• Significance & Background: In March 2020 The Centers for Medicare and Medicaid Services (CMS) issued blanket waivers in response to the emergency declaration related to the COVID-19 pandemic which, among other things, allows for care of acute psychiatric inpatients on the acute care unit of a hospital (CMS, 2020). This CMS waiver essentially allows for COVID-19 positive patients needing acute psychiatric admission to be admitted to an acute medicine unit if the acute psychiatric unit does not meet infection control needs.
• Evaluation Methods: To minimize delays in psychiatric care and longer lengths of stay due to the patient’s COVID-19 positive status and resulting admission to a COVID-19 medicine floor, inpatient psychiatry leadership consisting of the Unit Based Medical Director (UBMD), Patient Care Manager (PCM) and Clinical Nurse Specialist (CNS), developed a COVID-19+ Psychiatric Team to bring specialized psychiatric care to that patient located on the designated COVID-19 medicine unit. Through a series of meetings which included a Gemba on the designated COVID-19 medicine units the leadership group was able to develop a detailed plan to re-create inpatient psychiatric standards of care on the COVID-19 unit.
• Outcomes: The COVID-19+ Psychiatry Team consists of psychiatric nurses from the inpatient psychiatric units, an attending inpatient psychiatrist, a psychiatry resident, a Security Officer to prevent elopement for patients on involuntary holds, occupational therapists, and a psychologist to provide remote group therapy. The psychiatric CNS and PCM collaborate with their medicine counterparts to ensure the psychiatric staff have the necessary training and support around vital infection control practices. To date this team has been activated once to care for a patient requiring involuntary psychiatric admission.
• Implications: Inpatient psychiatric units lacking adequate infection control infrastructure may consider creating a team of psychiatric staff to provide psychiatric care to the COVID-19 positive patient needing acute psychiatric care admitted to a COVID-19 medicine unit under to the CMS waiver. 
• This poster and/or individual podium presentation can be presented virtually without any limitations.

Role of CNS in COVID-19 Pandemic
Capture Value of the CNS
Interprofessional Collaboration

COVID-19 RN Workflow: Leveraging Interprofessional and Staff Partnerships in Complex and Continually Evolving Clinical Practice

Significance & Background

As science rapidly evolved in the treatment for the novel coronavirus (COVID-19) there were constant changes to hospital best-practice guidelines. The institution’s COVID-19 intranet site housed over 200 documents, many with significant nursing practice implications. The pace of change and multitude of documents threatened patient safety, care, and outcomes. Nurses seeking current up-to-date clinical guidelines found it challenging to navigate the intranet site. The need for a comprehensive, easily accessible source of truth became critical. The unit-based Clinical Nurse Specialist (CNS) played an integral role in creating a succinct Inpatient Nursing Workflow and intranet site for frontline staff.

Evaluation Methods

Due to multiple constantly changing documents on the intranet, staff consolidated information by creating their own tip-sheets, workflows, and signage, thus reducing adherence to best-practice recommendations. Through rounding, in-person education, Shared Leadership Council (SLC) and Unit Educator (UE) collaboration, the unit-based CNS, in conjunction with the Nursing Professional Development Specialist team, optimized the delivery of practice changes. Their unified approach resulted in a streamlined and centralized Inpatient Nursing Workflow that incorporated guidelines from various interprofessional departments to clearly guide nurses caring for COVID-19 patients.

Outcomes

The revised “COVID-19 Inpatient Nursing Workflow” incorporated feedback from staff and operational leaders, as well as content developed by other disciplines that impacted nursing. This all-encompassing workflow became one of the most highly visited COVID-19 documents on the organization’s intranet site, exceeding 1400 views over 3 months. Additional rounding and continued engagement of staff through SLC and UE Forums has further solidified the importance of this standardized Inpatient Nursing Workflow. This is evidenced by staff using this workflow as their source for best practices and no longer creating their own content. Staff also escalate practice gaps to the appropriate interprofessionals.

Implications 

Constant adjustments to workflows and guidelines can easily create silos and gaps in best-practice application. Interprofessional collaboration and frontline engagement is integral to timely dissemination of, and adherence to, practices changes. The partnership between the unit-based CNS and NPDS helped connect frontline staff with interprofessional clinical guidelines that impact nursing care. Identifying gaps and consolidating information into an easily accessible document allows for fluid, transparent, and rapid information dissemination, providing a reliable source of information for staff in an ever-changing environment.

 

Role of CNS in COVID-19 Pandemic

Title: COVID-19 Response: Preparing critical care registered nurses amid crisis

Significance & Background:
COVID-19 has infected over 20 million people. Five million cases and 165,000 deaths are in the USA alone, placing enormous strain on healthcare resources. Critical care RNs were scarce due to travel-nurse availability and state mandated nurse-to-patient ratios. The CNS and educator developed a succinct critical care education program for ambulatory surgery and PACU RNs. Didactic and hands-on education were utilized in preparing RNs to care for COVID+ patients in non-traditional ICU settings. As infections surged, additional RNs were needed to meet staffing demands, thus the education was amended for telemetry RNs with previous critical care or step-down experience.

Evaluation Methods:
Over a period of six days, PACU RNs (n=52) and ambulatory surgery RNs (n=26) were provided a critical care refresher program. Furthermore, telemetry RNs (n=11) were trained and additional education is scheduled. The program focus included medication titration, critical care RN role during Code Blue, delirium assessment and prevention, sedation assessment, ventilator management, ICU assessment and documentation, arterial line management, and high flow oxygen delivery. RNs self-evaluated their familiarity of critical care skills utilizing a 7-point Likert scale, before and after the program. Results were analyzed using a 1-tailed paired t-test.

Outcomes:
The learners completed a pre- and post-intervention survey. Paired t- tests showed statistically significant improvement with familiarity in roles during Code Blue (p=0.04), sedation titration (p= 0.005), delirium prevention (p= 0.008) and assessment (p= 0.006), sedation assessment (p= 0.04), vasopressor titration (p= 0.008), ICU assessment and documentation (p= 0.004), ventilatory management (p= 0.03), and arterial line management (p= 0.002). Although not statistically significant, familiarity with insulin titration (p= 0.15) and high-flow oxygen delivery (p= 0.11) did demonstrate improvement. Further data to be presented upon acceptance.

Implications:
The collaboration between CNS and educator is imperative in preparing staff RNs to safely care for critically ill COVID-19+ patients. Moreover, it is essential to review existing staffing resources to identify RNs whose skills may be further developed in a pandemic. It is necessary to consider nursing learning needs, hands-on skills, and previous experience when developing an appropriate curriculum for providing high-quality, complex patient care.

CNS Improving Outcomes
Role of CNS in COVID-19 Pandemic
Patient Populations
Interprofessional Collaboration

COVID-19 Patient Populations Abstract

Title: Care of the COVID-19 Positive Patient

Authors: Allison Wier DNP, RN CMSRN AGCNS- BC APNP, Angela Burns BSN, RN, CMSRN

Significance & Background:  Since winter of 2019, a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused disease (COVID-19) in over 22,773,308 people with over 795,196 deaths across 188 countries (1). As the COVID-19 pandemic continues to emerge, care has had to transform to meet the patient’s unique needs at a Midwestern academic center. Since research on this virus is emerging, staff had to follow the current limited evidence and Center for Disease Control recommendations as the basis of their care. Care recommendations and PPE requirements were changing several times per week. Standards of care were needed to decrease confusion and improve patient outcomes.

Evaluation Methods:

Through analyzing the available evidence, a group of Clinical Nurse Specialists and educators developed and implemented guidelines to standardize care of patients with COVID-19. These guidelines focused on staff protection, personal protective equipment (PPE), and nursing-centered clustered care. 

A COVID-19 order-set was created. Care standards included: every 2-hour respiratory rates and continuous Pulse-ox, prone positioning, lab monitoring, and Aerobika. An early warning pathway for transfer to the ICU was developed and included a respiratory rate above 24 and oxygen needs greater than 5L.

While implementing the changes, the CNS provided real-time feedback to improve patient care outcomes and staff safety.

Outcomes:

There has been many positive patient outcomes since the care standards were operationalized. Since March 17, 2020, the hospital has had over 650 discharges with 23 deaths in the non-ICU setting. The average length of stay is 7.17 days. Once the early warning pathway was implemented, there was only one patient who required intubation on the floor.

CNSs were deployed to complete tracers with coaching on the proper use of PPE.  Since this occurred that has been minimal staff who have contracted the virus and compliance rates with the use of proper PPE have consistently been greater than 90%.

Implications

Clinical Nurse Specialists were able to quickly come together to standardize care for patients with Covid-19 and patient outcomes improved. The standard care guidelines have been implemented for patients in the ICU and med/surge care settings across the enterprise.

 Patient and family education at the time of discharge now includes precautions and interventions needed to prevent the spread of the virus across the community. The impact of these guidelines has increased the survival rate of COVID-19 patients at this facility and can have a positive impact across the country as well.

Reference

John Hopkins C. Coronavirus COVID-19 (2019-nCoV). 2020; https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6.

 

Role of CNS in COVID-19 Pandemic

Purpose: The purpose of this onboarding program is to ensure safety and resilience of Acute Care and PCU nursing staff during pandemic-related surge capacity.

Relevance/ Significance: Even in the early stages of the pandemic, healthcare organizations expressed concerns on staff availability to meet the projected demands. Lessons from the past pandemic responses indicated that healthcare organizations should prioritize training reserve staff and acquire the needed resources to expand capacity. Community RN extender are external staff working collaboratively with the primary RN to care for a group of patients and assume care and responsibilities within their scope of practice.

Strategy and Implementation:  The Community RN Extenders onboarding program included an 8-hour knowledge and skills class and two clinical orientation shifts (one in M/S unit and one in PCU). The class covered the overview of the extender role, scope of practice, onboarding pathway, documentation expectations, recognition of signs of early deterioration and information on prevention of hospital-acquired conditions. Additionally, the class included skills competency validation and tour of the Covid units and the entire hospital.

Evaluation/Outcomes:  Using the Kirkpatrick’s Training Evaluation Model (Levels 2 and 3), a retrospective pre-post survey revealed improvement in the participants’ understanding of surge staffing plan, guidelines of care, scope of practice, roles and responsibilities, and ability to perform necessary and critical skills.

Implications for Practice: Safety and resilience of nurses during a pandemic is an essential component of disaster preparedness. Effective staff onboarding established trust and confidence among team members and allow healthcare organizations to be more prepared for this unprecedented public health crisis.

 

Role of CNS in COVID-19 Pandemic

Background/Significance: In March of 2020, the Novel Corona Virus swept our nation and impacted healthcare around the world.  Overnight, organizations were forced to rapidly interpret the evidence and make decisions for COVID-19 patients and healthcare works.  Frontline caregivers struggled to interpret the fast-paced changes in regulations and guidance from around the world on a day to day, sometimes, hour to hour basis.  The organization’s culture of safety was at risk with the abundance of new and changing information, differing expert opinions, and an overflow of stakeholders.

 

Methods: Using the CNS framework, a CNS team was able to establish a structure for communication, infection prevention, patient care expectations and best practice sharing among 6 hospitals in an organization.  Sharp HealthCare instituted a disaster command center in which the role of the CNS was vital in communicating to the frontline by continuous rounding on the COVID-19 units to answer questions, guide patient care, problem solve, develop education, and facilitate training.  Through collaboration with experts including physicians, infection prevention specialists and other disciplines, a multidisciplinary, system-wide COVID-19 patient care guideline was established to promote quality and safety of patient care.

 

Outcomes: In a global pandemic, a system-wide CNS team was able to unify an organization by identifying key stakeholders, gain consensus, stabilize fears, and create a guideline for frontline empowerment. The team impacted structure, data collection, infection prevention strategies and promoted PPE conservation. Once established the team was able to track quality metrics through the quality variance reporting system and impact the Culture of Safety.  COVID-19 communication scored 77% favorable, and the COVID-19 care units maintained non-significant differences in their individual culture of safety metrics.  There was an initial increase in quality variance reporting, with a steady decrease since May 2020.

Implications: Standardization of patient care and creating a structure for communication is vital to an organization’s culture of safety and continuous improvement in the quality of patient care.  Healthcare organizations need commitment to the evidence to guide patient care while being adaptable and collaborative among all disciplines to deliver the highest quality of patient care.

Role of CNS in COVID-19 Pandemic

This presentation will describe the education and competency developed during the COVID-19 pandemic as well as discuss the challenges encountered in the clinical setting. The COVID- 19 pandemic strained the healthcare system as well as challenged the resources available to care for patients. During this time of uncertainty, hospitals were tasked to ensure that they had enough nurses to care for critically-ill COVID-19 patients.  The Academic Medical Center initiated a labor pool of nurses from various ancillary areas (i.e. Endoscopy, Cath Lab, Special Procedures, and other areas to name a few). Education and training was essential for frontline nurses to ensure safe practice and protection of patient and nurse. The Nursing Education team put together a comprehensive educational plan to ensure that nurses were trained, oriented and supported while caring for presumptive and confirmed COVID-19 patients.  The Nursing Education team created following curriculums:

• Modified Critical Care Class (4 Hours) - for critical care nurses working outside of the ICU to work in the ICU.
• Critical Care Partner Class ( 2 hours) - for medical surgical nurses to support critical care nurses
• Oncology Intermediate Care Cass (4 hours) - for oncology nurses caring for oncology patients that needed higher level of care.
• Back In the Saddle Class -a comprehensive review of all COVID-19 pandemic practice changes for staff coming back to clinical practice.

In addition to the multiple courses, curriculums and resources, the education team was key in supporting staff clinically and emotionally in the time of pandemic. Review of staff feedback from educational programs 2 months post COVID-19 peak. 

CNS as Project Manager
Role of CNS in COVID-19 Pandemic
Patient Populations
Capture Value of the CNS

In the setting of a surge of critically ill COVID-19 patients, our organization identified a critical need for resources to support the care of the patients in the ICU setting. Additionally, our organization identified an excess of resources in non-critical care setttings due to a cancellation of elective procedures and reduced volumes in outpatient areas. In alignment with the Society of Critical Care Medicine (SCCM) recommendations, there was an opportunity to utilize non-critical care nurses to provide direct patient care with oversight from the critical care nurse.Twelve training sessions were conducted with a didactic lecture portion, a skills lab simulation, electronic learning modules, and ICU nurse shadowing. Some of the training included drawing blood from an arterial line, oral care and in line suctioning of the mechanically ventilated patient, CRRT drainage bag changes, quality bundles to prevent VAE, and drip titration under direct supervision of the ICU nurse.  Following completion of the training, 57 nurses were trained and ready to be redeployed as needed to the ICU setting. Nurses from a variety of clinical settings were trained including acute care, perioperative services, and other nursing support services.Overall, the cross-trained nurses were able to provide support to five different ICUs throughout the hospital.The cross-training program helped to build relationships among nurses in both acute care and ICU while also building a better understanding of workflows outside of nurses' home units. Additionally, the cross-training program helped to develop and enhance the non-ICU nurses' knowledge and skill set. The cross trained nurses will be able to continue to support the ICUs and help reduce the burden that this pandemic and other potential crises can and will have on ICUs.

Other

The FDA approval of dabigatran in 2010 led a revolution in the practice of anticoagulation management. Whether the classification is called target specific oral anticoagulant, novel oral anticoagulant, or direct oral anticoagulant, these drugs drastically changed the approach to the acute and chronic management to prevent or treat venous thrombotic events. Yet the pharmacokinetics of each of these drugs presents unique challenges to the healthcare provider. The Institute of Safe Medicine Practices labels anticoagulants agents including direct oral anticoagulants and factor Xa inhibitors on the list of the high-alert medication. Furthermore, these drugs are associated with increase risk for readmission and emergency department visits. Effective July 1, 2019, the Joint Commission has added six new anticoagulation elements of performance within the National Patient Safety Goal (NPSG) 3.05.01. These elements of performance reflect the best practices of oral anticoagulation management to ensure patient outcomes.

Role of CNS in COVID-19 Pandemic

The US healthcare system has been overwhelmed by the need to focus all of its human and materials resources towards COVID. The numbers of patients requiring intensive care has surged beyond available ICU bed capacity – requiring the development of radical models of care; critical shortage of PPE has required triaging of resources, and new protocols to extend the use of PPE; lack of ventilators has required exploration of radical interventions such as shared ventilators between patients. These and other challenges have required the rapid development and implementation of new processes, procedures and guidelines to optimize provider safety and patient outcomes (Sprung, et al., 2020; Godoy, et al., 2020; Clarke, et al., 2020; Maxam, et al., 2020). Clinical nurse specialists play an important role in leading this work.

Clinical Nurse Specialist (2019) CNSs “are leaders and facilitators of change, coordinators of specialized care, and implementers of evidence-based care within/between organizations to facilitate quality improvement, patient safety, and lower healthcare costs (p. 10).”  As such, the clinical nurse specialist is uniquely prepared to optimize outcomes by assessing clinical practices in relation to evolving scientific evidence, and to intervening across the patient, nurse and system levels. The role of the CNS has never been more crucial than now.

While anecdotal reports of the impact of nursing and CNS practice are increasingly visible, there is a need to better understand the importance and impact of various aspects of the CNS role in responding to the COVID-19 crisis. To better understand the importance and impact of the CNS role in responding to the COVID-19 pandemic we conducted a survey of Clinical Nurse Specialists across the United States. This presentation will highlight key study findings.

Role of CNS in COVID-19 Pandemic
Interprofessional Collaboration

Significance & Background

In March of 2020, the outbreak of Novel Coronavirus happened suddenly and unexpectedly. Timely and accurate dissemination of the latest guidelines became a high priority. Early on we recognized the importance of interprofessional stakeholder involvement and engagement due to the complexity of our organization. This was a unique opportunity to harness the system leadership role that is at the core of Clinical Nurse Specialist (CNS) Practice. A CNS Leader gathered a team of inter-professional and inter-facility partners to address this rapid process improvement initiative to infuse evidence into practice, address barriers, and adapt in the face of numerous competing priorities.

Evaluation Methods

In the beginning, there was a lack of standardization and adherence to current guidelines. An intranet site was identified as a place to upload information, but it quickly became a repository for countless documents, lacking clinical influence. Utilizing Lean Methodology, there was continuous quality and process improvement via Plan, Do, Check, Act (PDCA) cycles. Gemba rounds allowed our team to see the excellent work, and some gaps in practice, in action. The interprofessional team created the content, developed an inventory of documents, and innovative tools were implemented to allow for efficient and effective access to relevant and timely updates.

Outcomes 

Revamping the COVID-19 intranet site as a central source of truth led to 40,000 hits per month. Leveraging a cloud-based online project management application allowed numerous stakeholder groups to contribute to the rapid dissemination of information with consultation, clinical review and oversight; currently, 500+ documents submitted for upload. This process improvement created standard information dissemination practices across the facets of our organization when appropriate, and offered the opportunity to influence unique situations or groups. Additional Gemba Rounds indicate the guidelines and resources are now more timely, relevant, and accessible and 97% survey respondents rate the tools as acceptable or better.

Implications for practice

Historically, large acute care settings and academic medical centers struggle to engage diverse interprofessional and interdisciplinary groups to align around a shared vision. Implementation and dissemination of rapid process and practice changes need efficient and effective collaboration to minimize disruption. Leveraging the CNS role as a leader, change agent, and clinical expert allows for the success of identifying technology and process improvement tools to implement and disseminate practice changes across a complex system during the global pandemic.

Role of CNS in COVID-19 Pandemic
Interprofessional Collaboration

During the COVID-19 pandemic, healthcare has seen many changes and challenges. In preparation for the uncertainty of what was to occur, the Clinical Nurse Specialists were able to step in and provide support, develop necessary personal protective equipment policies and patient care protocols. In everything we implemented or created, patient and clinical staff advocacy was our priority. We also provided education, were hands-on resources, and used evidence-based care to impact nursing practice. Using a tiered nursing model, we cross trained over 200 nurses to higher level of care areas in preparation for what we expected to see during our highest census times. By being at the bedside with the nurses, we found resource and educational opportunities and worked to close those gaps with the appropriate stakeholders. We collaborated with providers, administrators, and executive leaders to open a 7 bed COVID intensive care unit in a non-intensive care area. The Clinical Nurse Specialists’ expertise of what a new intensive care unit would need for success was essential to this process. As a result of these efforts, we know the providers and nursing staff felt supported and had the necessary resources to provide efficient patient care. Being a visual leader within the organization built relationships with many disciplines and allowed strong collaboration for improving our processes during the pandemic. The multiple roles the Clinical Nurse Specialists took on during this time were crucial to the planning and implementation of changes, and demonstrated positive outcomes within our organization.

Role of CNS in COVID-19 Pandemic

Background  

A Rapid Response System (RRS) is defined as a whole system that provides a safety net for patients who suddenly become critically ill and have a mismatch of needs and resources.

Purpose

To describe the role of a 24/7 proactive Rapid Response Nurse (RRN) and Rapid Response Respiratory Therapist (RRRT) team during the COVID19 crisis.

Methods

In 2017, an innovative 24/7 proactive RRN program was implemented to reduce clinical deterioration and cardiac arrest outside ICU. After implementation, a 60% reduction in cardiac arrests outside ICU was seen. In 2019, a RRRT was added to the team after cardiac arrest reviews showed that clinical deterioration was often due to respiratory pathology. In March 2020, this care model supported high acuity COVID19 patients on inpatient floors though high-risk screening, proactive rounding, and early intervention with non-invasive ventilation and high flow oxygen delivery on inpatient floors.

Results

2019 average monthly RRN activity was compared with RRN activity for March 2020, the COVID19 crisis. There was an increase in high risk screening (97%), RN consults (375%), Rapid Responses (22%), intubations (220%) and transfers to ICU (83%). During the same time period, the number of COVID19 positive patients went from zero to 340 and the number of ventilated patients went from 27 to 121.  RRN activity validates the ability of the proactive team to flex capacity to meet the COVID 19 patient surge. RN consults demonstrate that floor nurses felt comfortable calling for help from the team. These experts in the field provided clinical support for nurses and patients during the COVID19 crisis.

 

 

Role of CNS in COVID-19 Pandemic

Significance and Background:

Patients with novel coronavirus pneumonia (NCP) can present with hypoxemia and acute respiratory distress syndrome (ARDS). Proning is an evidence-based intervention recommended for intubated patients with severe ARDS. Proning improves ventilation-perfusion matching in the lung and increases the number of alveoli available to participate in gas exchange. Anecdotal evidence suggests that non-intubated self-proning has a positive effect on intubation and therefore intensive care unit utilization. A proactive self-proning protocol was targeted for positive NCP patients within the acute-care setting.

Evaluation and Methods:

A multidisciplinary approach was utilized to develop the protocol for clinicians to implement on patients who were positive or suspected for NCP.  Evidence based inclusion and exclusion criteria were included in the protocol.  Vital signs and the patient's response to self-proning were collected at predetermined intervals before, during and after proning therapy. Additionally, at the completion of therapy the length of time in the prone position as well as new adverse symptoms were documented. 

Outcomes:

Desired outcomes included improvement in oxygen saturation, reduced supplemental oxygen needs, and avoidance of intubation. Preliminary data has shown positive outcomes with all but two patients avoiding intubation. Adverse outcomes include new onset of headache, decreased blood pressure, inability to tolerate the prone position, or the need for intubation with ICU transfer.

Implications:

Collecting and quantifying data from the electronic medical record to validate outcomes has been a challenge.  Interdisciplinary collaboration between beside nurses, Clinical Nurse Specialists, Respiratory Therapists, Physical Therapist, and Medical Providers can greatly impact the continued efforts and success of this therapy. Patients meeting contraindications to proning were encouraged to assume lateral positioning while lying in bed, data was not collected around outcomes for these patients.

CNS Improving Outcomes
CNS as Project Manager
Role of CNS in COVID-19 Pandemic
Capture Value of the CNS
Interprofessional Collaboration

 Significance: Critical care nurses are a crucial asset to managing patients with ventilators, vasopressors, prone therapy, and other treatment modalities.The COVID-19 pandemic has placed an unprecedented strain on hospitals nation-wide, with an extra burden on critical care services. The acuity of the patients, increased numbers, and need for advanced treatment modalities increase demand for critical care nurses. Burnout, moral distress, quarantine, and family needs contribute to call outs, causing staffing shortages and unmanageable schedules. This session will explore the Clinical Nurse Specialist (CNS) role in implementing various training strategies, staffing models, cross training, and different scheduling methods to address the gap in critical care skills, knowledge, using the AACN Synergy model. CNSs applied their core competences in all three spears to improve patient outcomes. These strategies were effective in assisting nurse shortages, utilizing nurses of different training backgrounds, decreasing cost, avoiding furloughs, and enhancing nursing skills.

Evaluation Methods: Critical care skill ongoing pre and post survey, skills workshop evaluation, and preceptor and staff feedback

Outcomes: Successfully implemented strategies and methods for “COVID critical care” by education, training, while maintaining safety and quality, and ensuring adequate support of nursing staff amid the crisis. These efforts were also lead to increase hospital capacity to accommodate serge of COVID patients in the area by expanding critical care services to non-ICU areas and opening new COVID ICUs

Implications: Healthcare leaders will learn how cross-training strategies utilized at a larger academic institution could help with optimal utilization of available nursing staff to manage a staffing shortage during any disaster, crisis, or emergency.

CNS Improving Outcomes
CNS as Researcher
Role of CNS in COVID-19 Pandemic

Title: Studying the Psychological impacts on frontline health care professionals during the COVID-19 Pandemic.

The goal of this study is to determine prevalence of psychological distress in Nurses, Advanced Practice Providers, Respiratory Therapists, and Physicians during the COVID-19 pandemic, and to identify if interventions and higher measures of resiliency helped to minimize the prevalence of symptoms.

A secondary crisis lies deeper behind the coronavirus disease 2019 (COIVD-19) itself. It is important to gain an understanding of the psychological impact (anxiety, stress, depression, PTSD) on clinical workers during the COVID-19 outbreak, and their ability to restore their psychological wellness, especially considering the individual use of wellness/coping interventions and resiliency levels. Resiliency is the ability to recover after experiencing an adversity or trauma and return to a state of  individual normalcy. Based on early literature derived from China, results show that the current COVID-19 pandemic has direct negative impacts on healthcare workers mental health. Commonly, nearly 30% of nurses suffer from post-traumatic stress disorder (PTSD) during their careers. 

 

 

 

 

 

 

 

 

CNS Improving Outcomes
CNS as Project Manager
Role of CNS in COVID-19 Pandemic

Shared governance is a structure and process to promote quality outcomes through engagement of frontline staff in decision-making. The CNS is uniquely skilled to support and coach shared governance leaders. Using the example of lesson's learned at an academic medical center that sustained shared governance work through a global pandemic, CNSs can identify strategies that can sustain the process through transitions in leadership, staffing crisis, and organizational and global change. More than just having meetings, the CNS promotes shared governance that has measurable evidence to support accreditation by implementing routine evaluation using the Index of Nursing Professional Governance.

CNS Improving Outcomes
Quality Initiatives

The Feasibility and Adaptability of the PAST (Proactive and Aggressive Sickle Cell Disease Treatment) Model Across Three Medical Institutions in a Pre-COVID-19 and Post-COVID-19 Era.

CNS Improving Outcomes
Role of CNS in COVID-19 Pandemic

The COVID 19 pandemic presented unique challenges including nursing staff caring for a novel patient population. Concern arose that caring for this novel patient population could result in an increase in adverse outcomes. In an inner city academic medical center, a 24 bed surgical intensive care unit (SICU) transitioned to a COVID intensive care unit for a 2-month period. Many of the COVID 19 population had primarily medical diagnoses including ARDS associated with COVID 19. Building a network of CNS colleagues provided an arena for the SICU CNS to obtain consults for the challenges experienced with this patient population. The CNS of the SICU collaborated with the CNSs from the medical intensive care units (MICU) along with other CNSs throughout the hospital to share best practices for caring for this novel patient population and adapt protocols to optimize the care of COVID 19 patients. Much of the collaboration occurred via formal work groups which focused on protocols such as proning, PPE, utilizing extension tubing to keep IV pumps outside the room, in room communication, and infection prevention measures. However, the informal collaboration between CNSs cannot be overlooked as an important factor in optimizing care. The CNS from the SICU frequently collaborated with the CNSs from the MICU to discuss challenges and successes related to the care of this novel patient population. Frequent collaboration with the CNSs from the MICU who were also caring for COVID patients provided a platform to perform informal case studies and learn from specific patient cases while sharing best practices. Informal sharing of these best practices provided a forum for the SICU CNS to better educate the SICU staff and strategize how to continue to promote best practices for a novel patient population.

Patient outcomes evaluated included rate of Central line associated bloodstream infection (CLABSI), catheter associated urinary tract infections (CAUTI), and overall mortality.

No CLABSI or CAUTI were reported during the 2-month period. Overall hospital mortality was 7.8% at the time the SICU transitioned back to a surgical ICU. 27% of patient mortalities occurred in the SICU.

Collaboration between intensive care unit CNSs provided an opportunity to share best practices and may have contributed to positive outcomes during the COVID 19 pandemic. Building relationships with CNS colleagues and having forums to share best practices whether formal or informal can contribute to improved patient outcomes among various patient populations. The Director of Nursing Practice oversees the CNS group in this institution and is instrumental in fostering these relationships. Successful collaboration during the COVID pandemic can provide a framework for how CNSs across ICUs and service lines can come together to idea share and improve outcomes for patients.

 

CNS Improving Outcomes
Role of CNS in COVID-19 Pandemic
Patient Populations
Capture Value of the CNS

Purpose: The purpose of this initiative was to implement multimodal education frameworks and strategies to improve staff and physician knowledge, skills, and attitudes (KSAs) and overall practice outcomes related to COVID-19.

Relevance/Significance: In late 2019, the Coronavirus evolved to infect the human respiratory system (SARS-CoV-2 also known as COVID-19). On March 11, 2020, the World Health Organization (WHO) labeled this outbreak as a pandemic. During March, this organization recognized the importance of providing education on COVID-19 considering how rapidly information regarding the virus was evolving.

Strategy and Implementation: Initial sensing sessions were performed with staff related to COVID-19. Using Bloom’s Domains of Learning, the CNS team identified knowledge, skills, and attitudes to develop the education and created learning objectives guided by Bloom’s taxonomy of verbs mapped to Benner’s Stages of Clinical Competency. Education was provided to staff and physicians through one-on-one and group instruction, case studies, question and answer, video/media, and simulation. Kirkpatrick’s Four Levels of Evaluation was used to evaluate the education through a retrospective pre-post assessment and incident report COVID-19-related practice events.

Evaluation/Outcomes: Among the 346 respondents participating in the retrospective pre-post assessment, the majority (49%) were clinical nurses and lead clinical nurses from the critical care and emergency department areas. Results from the assessment demonstrated a highly statistically significant (p<0.001) improvement in staff and physician KSAs related to COVID-19. Additionally, there was a 40% reduction in incident reporting related to COVID-19 practices from March-July 2020.

Implications for Practice: Using multimodal education frameworks and strategies can improve clinical practice and should be considered for all healthcare-related education.

Capture Value of the CNS

The clinical nurse specialist role can vary across practice areas and health system service lines with each area assuming responsibility for the coordination of onboarding and orientation practices. An absence of standardization in the operations, onboarding, and orientation of the clinical nurse specialist role has resulted in a lack of role clarity and visibility within organization in addition to a decrease in job satisfaction. 

The following presentation highlights the findings of a collaborative of clinical nurse specialists from the unit level and system-level who was allocated the responsibility of investigating current organizational practices regarding onboarding by the chief nursing executive. Onboarding consists of the recruitment, credentialing, and interviewing of applicants for clinical nurse specialist positions within the organization.  The overall aim of findings is to improve and standardize practices associated with the role within the organization to optimize role visibility and utilization.

CNS as Project Manager
Role of CNS in COVID-19 Pandemic
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Title: Clinical Nurse Specialists address the unique needs of pediatric and perinatal patient populations during COVID-19. 

Significance and Background: Armed with the preparation and training unique to a Clinical Nurse Specialist, rapid change was needed throughout all three spheres of influence (patient, nursing, and organization) to meet the unique challenges presented during a pandemic within the Pediatric and Women’s Service Lines. This work included but was not limited to development of population specific crisis care standards, nursing care guidelines for COVID positive patients, visitor policy development unique to each patient population (since the “no visitor” policy for adult Med-Surg patients did not apply to children and laboring mothers), and code blue modifications to protect teammates and prevent spread of COVID  during this pandemic. 

Evaluation Methods: The existence of an integrative CNS team across the system, with specific focus on individual service lines, allowed for quick identification and response to immediate needs the pandemic presented. 

Outcomes: A streamlined approval process positioned the CNS as the subject matter expert, leading system work and collaborating directly with senior leadership to implement rapid change. This enhanced teamwork and collaboration amongst diverse professional roles within the system lead to both standardized and population specific strategies and practice changes. 

Implications: The diversity and adaptability of the CNS further highlights the value and need of the CNS role in a complex hospital system. The CNS team worked cohesively and responded to the abrupt shift in purpose to meet the diverse needs of the specific patient populations they served during COVID-19. The influence of the CNS to drive change reaches beyond the needs of a pandemic and is a valuable asset to optimze care within a multi-hospital healthcare system.

 

CNS Improving Outcomes
CNS as Researcher
CNS as Project Manager
Role of CNS in COVID-19 Pandemic
Interprofessional Collaboration

Everyone in healthcare is experiencing increased demands on their time, resources, and energy; this, combined with systems that are not designed to support the expanding daily work, has resulted in increased rates of burnout.  Burnout among healthcare professionals is reaching epidemic proportions, with over 50% of physicians and 30% of nurses reporting signs of burnout.  While the evidence demonstrates that burnout is becoming a norm in healthcare, it is rarely discussed among these professionals.  Too often, burnout is considered a personal problem affecting only the person experiencing burnout; however, in healthcare, burnout also affects the entire healthcare system. 

Burnout has significant impact in healthcare, including lower-quality patient care, reduced patient and staff safety and patient satisfaction, and increased staff turnover.  It has also been demonstrated that there is a statistically significant correlation between nurse burnout and increased healthcare-associated infection rates. 

While burnout affects all aspects of healthcare, it is frequently perceived as someone else’s problem.  Individuals feel like they cannot cope with the demands of their life and be effective at their work.  Too often, they don’t want to ask for help, because they don’t want anyone to know they are experiencing burnout.  They worry that they may not be appreciated or, even worse, thought of as incompetent if anyone realizes that they are experiencing burnout. 

Leaders and their staff both experience the pain of burnout, frequently at the same time.  As a leader, one needs to not only understand the factors that lead to burnout but also the support necessary to recover from it.  Leaders need to help staff recognize that burnout is not a sign of failure and support them in their journey back from burnout. 

In this session, we’ll review the classic factors leading to burnout and distill them into a model of burnout focused on perceived personal efficacy and personal agency.  Pulling research and writings from many disciplines, you’ll learn how to think about burnout in a way that enables you to prevent it – or recover from it – for yourself or the staff you support. 

Capture Value of the CNS

The value a CNS can bring to a healthcare organization is often misunderstood. The Clinical Nurse Specialist (CNS) is uniquely qualified to lead evidence-informed process improvement initiatives to ensure quality cost effective patient outcomes by supporting nursing practice, and optimization of system processes. CNSs are challenged with demonstrating their value and impact.

The value and impact of the CNS has been historically demonstrated based on specific topics. NACNS has provided a cost analysis toolkit to assist CNSs with demonstrating their value and impact. CNSs are challenged with demonstrating to their institutions the impact and value of their work. This interactive presentation will assist CNSs in developing their personal CNS impact marketing plan that would demonstrate their value and impact on the healthcare organizations bottom line. We will develop marketing strategies to raise the visibility of the CNS within the organization.

The ability for a CNS to develop an impact marketing plan demonstrating their work, its value and impact on moving the healthcare organizations supports the CNS competency of: Disseminates CNS practice and fiscal outcomes to internal stakeholders and the public.

CNSs demonstrating their impact and financial value in relation to quality cost effective patient outcomes supports the resurgence of the CNS as a valuable team member during the changing healthcare environment.

Role of CNS in COVID-19 Pandemic

In early spring 2020, a global pandemic started to make its mark in the United States. A large healthcare system in North Carolina recognized the need to act and prepare before the potentially ravaging effects would burden the healthcare system and those working in it. As specially trained Advanced Practice Registered Nurses (APRNs), the Clinical Nurse Specialists (CNS) within a large level 1 trauma, quaternary care facility quickly assumed a leading role in preparations for the emerging COVID-19 crisis.  A team of critical-care CNSs developed a crisis staffing model and standards of care to guide safe practice in the setting of a surge of COVID-19 patients. This presentation aims to highlight the unique contributions of the critical-care CNS during the novel COVID-19 pandemic. Tactics to support the frontline staff such as Care of the COVID ICU Patient Guide and development of an interprofessional prone team during a time of ever-changing guidelines and navigating the unknown will be presented. Products of this work and learnings can be applied to future crisis management beyond the COVID-19 pandemic.  

CNS as Project Manager

This presentation will introduce the non-project manager to concepts which can be easily applied to a project to keep the endeavor on track and mvoing towards a successful implementation.  Project management tools will be discussed along with approaches for displaying results in the most effective manner. In addition, team dynamics will be addressed as well as the human factors which impact successful projects and change.  Attendees will have an opportunity to practice project management principles during a case study.

Quality Initiatives
Patient Populations
Capture Value of the CNS

In a large academic medical center with 31 Clinical Nurse Specialists (CNSs) practicing across 27 inpatient units, defining the CNS role and providing opportunities for professional development and mentorship has fostered CNS engagement. We designed a CNS orientation and development program, framed by the three spheres of influence and comprised of three specific components: (1) Orientation, (2) CNS Forum, and (3) Advancement and Recognition. These program components function in complement to deliver varied types of professional support to new and experienced CNSs. Organizational scholars describe that colleagues exchange emotional and tangible assistance, known as professional support, to help one another meet job demands. Types of professional support include mentoring, coaching, social support, and collaborative problem solving. Access to each improves work-related outcomes such as employee satisfaction, commitment, compensation, and promotion. In this symposium, we will describe each component of the CNS onboarding and development program, the support delivered to develop CNSs from novice to expert, and the associated outcomes.

 

 

 

 

 

Evaluation Method:  We assessed CNS turnover and employee engagement data and elicited feedback directly from CNSs to identify ways to strengthen orientation and development.

Outcomes: Since 2017, CNS turnover decreased; 42% of CNSs are tenured with at least five years of experience. Anecdotally, CNSs report a strong sense of teamwork and collaboration.

Implications

Developing an orientation and development program that mentors CNSs from novice to expert is beneficial not only to the healthcare system, but the nurses and patients it serves.

Other

Significance & Background

To ensure newly hired Clinical Nurse Specialists (CNSs) successfully transition into— and remain in— their roles, they must participate in a comprehensive orientation program. Across numerous industries, robust orientation programs have been shown to improve retention, engagement, and job performance. At our organization, an increase in CNS turnover prompted an assessment and redesign of our CNS orientation program. This presentation describes the standardized program created to support newly hired Clinical Nurse Specialists (CNSs) and the resulting impact on CNS turnover.

 

Evaluation Methods

In 2018, an evaluation of CNS turnover rates, exit interview data, and hiring practices over the previous 3 years revealed that attrition within 2 years of hire was a key contributor to high turnover rates (2015:18.5%, 2016:10.3%, 2017: 16.7%).

Outcomes

In response, we implemented a multi-tiered interview process, developed a standardized onboarding guide, and bolstered orientation to include frequent performance feedback, peer mentoring, deliberate networking, and focused leadership development, framed by the three spheres of influence. Since implementation, CNS turnover has declined to 9.4% in FY18 and 19. Notably in both years, CNSs who turned over did so voluntarily, leaving for family reasons or to pursue a new opportunity within the organization.

Implications

CNSs have a unique and complex role, which requires a standardized and comprehensive orientation. Leveraging the NACNS core competencies to construct a process for effectively orienting newly hired CNSs helps to define role expectations and promote integration into the team for novice and expert CNSs, alike, leading to reduced turnover.

 

Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Significance/Background

The Clinical Nurse Specialist (CNS) Advancement and Recognition Program acknowledges CNSs for their contributions in leading care quality and advancing nursing practice and clinical knowledge. Three CNS levels are recognized. The CNS IV is an entry-level position for novice to advanced beginner CNSs who influence practice at the unit level. The CNS V is an advanced position for proficient CNSs who have expanded their scope to influence change across multiple units. The CNS VI is an expert who influences practice change across the institution to demonstrate improvements in patient, nurse, and/or organizational outcomes.

Evaluation Methods

To evaluate the CNS applying for advancement, the CNS candidates prepare and submit a portfolio including: curriculum vitae, letters of recommendation, volunteer activities, and scholarly work. Framed by the three spheres of influence, candidates present how they impact clinical care, develop clinical nurses, and advanced the organizational imperatives.

Outcomes

Peers provided written feedback about the candidate’s presentation and portfolio. Peers suggested recommendations for future professional growth and development. Since fiscal year 2016, 12 CNSs advanced to level V and four CNSs advanced to level VI. On average, twice a year, two to three CNS candidates advance.

 Implications

The CNS Advancement and Recognition Program supports advancing CNS candidates by allowing them to showcase their accomplishments to a committee of peers while leveraging a network of support. The CNS team values the presentations, learning from their colleagues while supporting each other’s professional growth and development.

CNS Improving Outcomes
Capture Value of the CNS

Background & Significance: Literature demonstrates a supportive work environment which fosters professional growth, team problem solving, and social collaboration is correlated with increased job satisfaction, decreased job stress, and burnout. This presentation describes a Clinical Nurse Specialist (CNS) Forum developed at a large academic medical center to provide support that extends beyond CNS orientation.

Evaluation Methods: The CNS team was anonymously surveyed using the Advisory Board Employee Engagement survey to determine the professional and personal needs for both new and experienced CNSs. The results of the survey revealed the ‘Employee Support’ category, specifically “manageable workload”, represented the greatest area of opportunity relative to the national benchmark.

Outcomes: The CNS Forum was created to support the CNS development and collaborative problem solving. Topics were identified and disseminated in advance of the monthly forums. Attendance was encouraged, but optional. CNS attendance per session averages between 20% to 65%. Forum topics have included: utilizing efficient tools to collect data, review of EQUATOR reporting guidelines, book club discussion, CNS project collaboration, time management strategies, mindfulness strategies, and social events. The Forums have been established for over a year and has provided information on shared resources available within the healthcare organization and the university.

Implications: The Forums provide time for peer mentorship, coaching, socialization, and problem solving. Providing professional development and team collaboration has increased job satisfaction and retention rates among the CNS team.

Role of CNS in COVID-19 Pandemic

Responding to emerging crises in healthcare requires a complex, multifaceted approach. The COVID-19 pandemic has resulted in a global health crisis that has emphasized the need for advanced clinical leadership to navigate through these unprecedented times. Clinical Nurse Specialists (CNS) are strategically positioned to assume a leading role in preparing for these events. In early 2020, healthcare systems were tasked with developing organizational policies and procedures to provide guidelines of care as COVID-19 rapidly spread, increasing healthcare demands. This presentation aims to highlight the ability of the medical-surgical CNS team within a large hospital system, located in the southeast region of the U.S., to lead an initiative to develop crisis care standards for nursing staff and standardize patient plans of care through multidisciplinary collaboration. Incorporating the three spheres of influence (patient, nursing, and system), this high functioning CNS team was able to successfully address the needs of patients, nursing staff, and the system. The educational preparation and unique ability of the CNS to work both efficiently and effectively in each sphere demonstrates CNS leadership in crises care development and pandemic preparedness in a large healthcare system.

CNS Improving Outcomes

 

Purpose/Objective: This quality improvement project examined the effectiveness of an opioid awareness training program by decreasing naloxone rescue occurrences on a cardiac observation unit.

 

Description of the Project/Program: Program effectiveness was measured on recognition of opioid respiratory depression and treatment. Clinical nurses completed a Knowledge, Skills, and Attitude assessment before and after participating in an opioid awareness training program.

 

Results: Following participation in the training program, there was significant improvement in nurse’s ability to recognize and treat opioid related respiratory depression and a reduction in naloxone rescue doses.

 

Conclusion: The results of this project demonstrated that opioid awareness training improved nursing opioid- management with patients and improved opioid therapy monitoring strategies.

Implications for Nursing: This program benefits patients receiving opioid therapy by improving nursing practice of caring for this patient population.

CNS Improving Outcomes
Quality Initiatives
Patient Populations
Interprofessional Collaboration

Admission bloodwork for newborns in the Neonatal Intensive Care Unit (NICU) is drawn from arterial punctures or umbilical catheter. Phlebotomy loss is 6-8ml, about 10-20 ml/kg.  This blood loss can disrupt blood flow, negatively impacting hemodynamic stability thus increasing potential need for vasopressors and blood transfusions. Especially in conjunction with extreme prematurity, the risk of Intraventricular Hemorrhage (IVH) and Necrotizing Enterocolitis (NEC) increases.

 

Emerging literature suggests use of umbilical cord blood can be used for newborn blood work.  This may have numerous positive outcomes, including decreased need for early blood transfusions, timely results, and increased blood volume for cultures.

Neonatal Clinical Nurse in role of Quality Improvement Facilitator, CNS and Medical Director established collaborative plan with Labor & Delivery Clinical Nurse and CNS to expand on the practice of cord blood draws for gases to include NICU admission lab work. Additional collaboration involved leadership of Blood Bank and Laboratory. Planning was put in place to validate results to affirm accuracy like that in the literature. A training program for L&D nurses to reinforce best practices drawing blood cultures, transfer techniques and order of draw was implemented. Blood culture contamination rate and comparison of labs would be considered prior to full implementation.

Outcomes include: 52 blood culture comparisons with 2 from cord blood and 1 from infant draw; 42 CBCD comparisons: 3 platelet count discrepancies.

Implications:

Newborns in NICU will experience:

• Less pain and trauma due to less invasive method of obtaining admission lab work.
• More timely results of blood culture and CBCD
• Less need for blood transfusions
• Less incidence of hemodynamic instability, IVH, NEC, etc..

Consider spread of practice to newborn nursery for infants at high-risk for early onset sepsis despite being asymptomatic which allows for earlier antibiotic administration.

CNS Improving Outcomes
Quality Initiatives
Patient Populations

Older adults have an increased risk of falling which leads to a decline in their continued function and independence. The objective of this study was to prospectively measure efficacy of the 8-week A Matter of Balance (MOB) falls reduction program in increasing Functional Reach (FR) and reducing Timed Get Up and Go (TUG) scores among elderly participants (age > 65 years). A one-tailed paired T-test was used to compare FR pre- and post-score mean differences. A one-tailed Wilcoxon Signed Rank test was employed for comparing median differences of pre- and post-test TUG assessments.Significant findings (p = .002) revealed that the MOB intervention improved FR scores (n = 120) by an average of 0.59 inches from pre-test to post-test. Significant differences (p < .001) between median pre-test and post-test TUG scores (n = 119) were also found. On average, TUG scores were reduced by 1.25 seconds following completion of the intervention. The MOB program was effective in improving both FR and TUG scores among elderly participants. At-risk individuals > 65 years of age should be encouraged to participate in the MOB program to decrease their risk of falling while promoting their independence. 

CNS Improving Outcomes

Purpose

The use of indwelling urinary catheters predisposes a patient to a catheter associated urinary infection (CAUTI). The estimated average excess cost for care is $13,793. From January – June of 2019, the NSICU had a total of 7 patients harmed with a CAUTI. Historically, the unit has seen an average of 1 CAUTI per month. Compared with other critical care units within the organization, NSICU had a significantly higher rate of infection and catheter utilization. The purpose of this quality improvement project was to develop evidence-based practice strategies to decrease the utilization of urinary catheters by 10% and reduce the rate of CAUTI by 50% within 3 months.

PICO Question/Aim Statement

In adult neuroscience intensive care unit patients, does use of a ‘mindfulness’ guideline for indwelling urinary catheters, compared to standard of practice, result in a reduction of utilization of urinary catheters and rate of CAUTI?

Evaluation of the Literature

Analysis of all infections found urinary catheters were utilized without clinical need, urine cultures were being ordered frequently for isolated fevers, cultures were being obtained from catheters that had been indwelling for several days, and frequent occurrence of fecal incontinence which could lead to contamination of the catheter.

A review of the literature was done to search for recent evidence. The Agency of Healthcare Research and Quality (AHRQ) evidence-based guidelines and toolkit was used to guide practice change. Recommendations from these guidelines include reducing unnecessary insertion, avoidance of random urine culturing, and recommendations for care and maintenance.

 Methodology/Implementation

A team was established that included Advanced Practice Registered Nurses and bedside clinical nurses. A new guideline was developed that included “mindfulness” prior to ordering insertion, avoiding reactive urine cultures for isolated fevers, alcohol caps on sampling ports, and increased catheter care to every 4 hours using hospital supplied castile soap wipes. Urine cultures were no longer obtained from any catheter that was > 48 hours due to the increased risk of biofilm.

 Evaluation Measures

Infection Prevention reports for catheter utilization and CAUTI were monitored monthly. Bedside audits were done by the leadership team daily on all patients with a urinary catheter to provide real time coaching.

 Outcome

The unit met the goal for utilization within 3 months and has maintained utilization below the national mean. There has been 100% reduction in CAUTI since implementation with an estimated cost saving of $165,516. A zero CAUTI rate has been sustained for over 300 consecutive days.

Discussion

Reducing utilization and CAUTI is a mission that requires collaborative work with providers who prescribe urinary catheters and clinical nurses who care for them. In NSICU, a team of Nurse Practitioners manages patients under supervision of the Intensivist. The role of the Clinical Nurse Specialist leading collaborative efforts between these two nursing roles, reviewing the literature and implementing new standards has led to a successful quality improvement project and improved patient outcomes.

CNS Improving Outcomes
Quality Initiatives

Significance and Background: At the end of 2018 there was an increase in patient falls in the adult non-ICU spaces of a Midwestern teaching hospital. Review of the falls revealed a trend of bed and bed alarm related factors contributing to these cases. At the same time, the hospital standardized to a bed with smart technology monitoring abilities that could capture and alert staff to changes in pre-set safety parameters. A core team of fall prevention committee members, led by two clinical nurse specialists, created a standard for bed use and monitoring in addition to a rounding plan for compliance, education and assessment of outcomes. Research objectives: The project had 3 identified objectives. (1) Reduce the fall rate over a three month period post intervention implementation; (2) Reduce the number of falls over a three month period post intervention implementation; and (3) Maintain unit compliance to appropriate smart bed monitoring functionality (bed light equals green) at a rate greater than 85%. Methods: The intervention for this work centered on educating and promoting the use of appropriate smart bed monitoring technology for the first two weeks of initiation. After that two week period, groups of two to three members of the core fall prevention team rounded on 15 units looking for compliance with the use of appropriate smart bed monitoring technology from mid-March until the end of April. The beds would illuminate green when the pre-set safety parameters were in place and teams used an electronic data collection tool to track and measure compliance. On the spot education and coaching took place for any fall outs and results were delivered to unit leadership following the rounding. Evaluation Methods: Fall rate and number were assessed for three months prior to the initiation of the weekly focused rounding. Weekly rounding began in March of 2019 and fall rates and numbers were monitored in the non-ICU adult spaces for April, May and June. Compliance to bed safety parameters being set correctly was also measured. This intervention would be considered successful if there was a reduction in overall fall number and rate, and a smart bed monitoring functionality compliance greater than 0.85 or 85%. Outcomes: There was a reduction in fall rate post-intervention implementation by 22.4% from 3.17 to 2.46. There was a reduction in overall number of falls by 21.6% from 111 to 87 in a three month period. Of the 15 non-ICU adult units in which this intervention was initiated, 12 units had a reduction in both fall rate and number. This is indicative of an 80% unit improvement rate. There was an increase in compliance to smart bed monitoring functionality by 61% from 30% to 91%. Implications: Dedicated, focused rounding with education and coaching in addition to standardized use of smart bed monitoring of pre-set bed safety parameters dictated by patient condition significantly reduced falls in the adult non-ICU space. This technology and rounding plan has the potential to be generalized to the ICU space as well. The ICU version of the smart bed monitoring functionality is more complex and would take increased dedicated education for competency from staff. In addition, this rounding plan proved successful and will be mimicked for future initiative roll outs. 

CNS Improving Outcomes
Role of CNS in Diversity and Inclusion
Quality Initiatives

Problem: Bullying and Incivility have been an issue in the nursing profession for a long period of time. The main impact on staff nurses is stress, anxiety, depression and psychosomatic illnesses.  Being in an atmosphere where there is incivility and bullying could cause new graduate nurses to leave their current positions or the nursing profession entirely.

Objective: The overall purpose of this quality improvement project was to increase nurse’s knowledge of the impact of bullying and incivility on new graduate nurses and explore strategies to decrease or stop this behavior in the workplace.

Methods: Using strategies from a Civility Tool-kit, an hour-long educational program was implemented over the course of four weeks to preceptors on three acute care medicine units and one observation medicine unit with a focus on decreasing workplace bullying and incivility toward new graduate nurses. A pre-and post-survey was given to the preceptors to assess their response to the intervention. The Clark Civility Index tool was given to new graduate nurses to compare bullying and incivility behaviors towards them pre and post implementation of the educational sessions.

Anticipated Contribution to Practice: It is anticipated that this program will increase preceptor knowledge and awareness of bullying and incivility with the overarching goal of empowering them to become champions and advocates for civility in the workplace. Preceptors can help break the cycle of bullying and incivility which will promote a respectful, civil, and safe environment for new graduate nurses to flourish which can also improve their retention.

 

CNS Improving Outcomes
Quality Initiatives
Interprofessional Collaboration

Title: Prevention of Perioperative Pressure Injuries (PPI)

Description: Patients who have undergone surgery at Tripler Army Medical Center (TAMC) have developed PPI at an increasing rate.

Objectives: In perioperative patients undergoing surgery at TAMC will an evidence-based PPI prevention bundle compared to current practice result in a decrease in PPI with a goal of decreased occurrences in the year following implementation.

Background: Incidence of PPI at Tripler Army Medical Center (TAMC) has increased from 3 in 2018 to 7 as of December 2019. National incidence of PPI has a pooled incidence rate of 15%. Evidence supports the use of a trigger system (Scott Triggers) for initiation of PPI prevention modalities in the reduction of PPIs.

Methods: 20 articles were compiled utilizing the CINAHL and PubMed databases. Evidence synthesized supports the use of a PPI bundle in concert with skin assessment tool to achieve reduced occurrences of PPI. A multidisciplinary team of CNSs, nurses, certified wound ostomy nurses, surgeons, leaders, and educators created an evidence-based PPI prevention bundle that includes PPI risk assessment trigger tools, workflow changes, preventative protection of pressure dependent skin with five layer silicone dressings, communication tools, root cause analysis, and wound care follow up.

Findings: The project was initiated December, 2019 with PPI’s being tracked monthly. Preliminary results will be available for presentation by March 2020. PPI tracer data to support compliance with bundle initiatives include the use of Scotts Triggers risk criteria, patient positioning, use of PPI prevention interventions, 24 hour and 72 hour post-operative rounding on 10 patients per month.

Implications for military nursing: A multidisciplinary team in concert with leadership is influencing the perioperative environment to embrace a culture of quality, safety, and continuous process improvement related to the prevention of PPI. Once thought of as a clinical problem specific to inpatient care, pressure injury prevention in the perioperative setting extends prevention into the preoperative, intraoperative, and postoperative phases of care to achieve surgical outcomes free of PPI to support better care, better health, lower cost, and increased readiness.

Role of CNS in Diversity and Inclusion

In early 2009, two master’s prepared nurses recognized the need for a more culturally competent healthcare organization. Thus, a Diversity Council was developed from facets of Planetree, and aspects of the then 14 forces of Magnet. Support was instrumental from nursing leadership and Human Resources (HR) to establish a meaningful forum for staff to explore their own thought processes regarding diversity. Within 3 years, the certification of Clinical Nurse Specialist (CNS) was achieved by both nurses. Today as APRN’s, the organization fully embraces our knowledge base surrounding the importance of cultural diversity and the critical need for inclusion across the health system. The CNSs are a consultant to HR on policies that touch on culturally sensitive topics. This is also present within the inpatient setting in regards to the diverse patient population that we served. As we live through the trials of 2020, the CNSs are currently dedicated to helping staff debrief on matters that can ultimately affect the delivery of care within a healthcare organization.

CNS Improving Outcomes
CNS as Researcher
CNS as Project Manager
Quality Initiatives
Patient Populations
Interprofessional Collaboration

Collaboration in the Burn Team:  Developing a Self-Efficacy Enhancing Pain Management Protocol for Adult Patients.

 

Significance and Background

Acute burn pain is difficult to manage, and poorly managed pain can lead to deleterious consequences such as post-traumatic stress disorder, acute stress disorder, prolonged recovery, and long-term dependence on opioids.  It was the goal of this verified burn center to investigate the multiple considerations inherent in effectively managing pain, assess weaknesses in our current approach, and develop a comprehensive strategy to improve patient outcomes.  A CNS-led multi-disciplinary team comprised of nursing, medical, and mental-health clinicians worked together to develop a multi-modal pain management protocol aimed at improving pain management through self-efficacy-enhancing interventions.

Evaluation Methods

A needs assessment was conducted by performing a comprehensive literature review of burn pain management.  An anonymous staff survey was distributed asking burn team staff to rate the efficacy of various aspects of current pain management practices, identify perceived weaknesses and possible improvements in burn pain management.

A quasi-experimental pre-test/post-test design has been employed to evaluate protocol efficacy measuring pain scores, morphine milligram equivalents (MMEs) and coping self-efficacy (CSE) scores with a sample goal of 60 adult burn patients. Staff nurses will be surveyed three months post protocol initiation.   

Outcomes

The literature review supported the development of a protocol that synergistically employs patient/family education, pharmacological intervention, and non-pharmacological intervention to improve pain and anxiety management and enhance patient self-efficacy.  Per survey results, consistent setting of goals for pain management, and consistent use of nonpharmacological interventions were identified by 71% of survey respondents as needing to be improved upon.  Lack of effective patient education and patient coping skills were identified respectively by 78% and 76% of respondents as barriers to successful pain management.

Protocol outcomes are currently being measured.

Implications

This quality improvement process has highlighted the importance of interprofessional collaboration in identifying and addressing practice gaps in a team-oriented practice setting.  Standardizing multimodal interventions may enhance self-efficacy, improve overall pain                  management, and potentially reduce harms associated with poorly controlled burn pain.  We hope our practice improvement process can serve as a model to other multi-disciplinary teams in impacting improved patient outcomes and lead to further research and progressive efforts in improving pain management within the burn community.

 

 

CNS Improving Outcomes
CNS as Researcher
Quality Initiatives
Capture Value of the CNS
Interprofessional Collaboration

Evidence-based practice is a problem solving approach, using theory-derived, research based information in making decisions about care delivery in consideration of individual needs and preferences. 

Our service line has adopted a unique model, which pairs a PhD Nurse Scientist and a DNP Clinical Nurse Specialist to generate and evaluate evidence that directly impacts the delivery of care and includes collaboration with the clinical staff. 

This model empowers the staff to affect the care that deliver in a positive manner. It challenges the standard task oriented nursing care and allows clinical staff to more deeply understand the evidence and process behind the care that they deliver.

Role of CNS in Diversity and Inclusion

This offering aims to improve the experiences of transgender men in seeking gynecological and reproductive health care. It will present the best available evidence around these experiences focusing on a systematic review that synthesized the qualitative evidence into 5 synthesized findings.1) Negotiating the binary system, 2) Navigating the cis-normative world, 3) Healthcare access adaptive behaviors, 4) Verbal and non-verbal discrimination, and 5) Provider knowledge and trustworthiness. These findings will be discussed to the extent allowed by the alotted time. 

CNS Improving Outcomes
Capture Value of the CNS
Interprofessional Collaboration

Transparency and structured reporting around nursing quality metrics affects engagement and acceptance of best practice. It also minimizes the likelihood of work duplication. The clinical excellence team in this organization identified inconsistent reporting as an opportunity to impact nursing sensitive outcomes. Through structured accountability and leadership, the CNSs evaluated evidence and collaborated with an interdisciplinary team to drive change ensuring best practice. With strategies in place for outcome improvement, the team created a dashboard for the leadership team which is shared on a monthly basis. This promotes transparency and fosters accountability among leaders for sustained change.

Each CNS evaluates individual outcome data, determining effectiveness of practice changes, which is collectively shared on the metric dashboard each month. By standardizing policies, verifying available supplies and resources, and coaching and mentoring bedside clinicians, the CNS promotes use of evidence-based initiatives across the hospital.

Responsible for five nurse-sensitive indicators, the team has shown success through a reduction in aspiration pneumonia and blood stream infections by 70% and 65% respectively. This impact equates to a cost avoidance of $600,000. Urinary catheter infections, pressure injuries and falls all have continued opportunities for improvement. Transparency in reporting facilitates leadership support and allocation of necessary resources.

A standardized reporting structure highlights the CNS expertise in systems leadership, coaching and mentoring and integration of evidence into practice. Additionally, engaging leaders as participants is a crucial element necessary for sustainment of practice changes. 

CNS Improving Outcomes
CNS as Researcher
Interprofessional Collaboration

• Significance & Background:  The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that over two-thirds of children have at least one traumatic event before the age of 16 and over 25% witnessed or experienced a traumatic event before the age of four. The application of Animal Assisted Therapy (AAT) in therapeutic interventions in schools show promising results and provides researchers opportunities to explore the scientific evidence of human-canine interactions. The Clinical Nurse Specialist (CNS) can support collaborative efforts between school counselors and nurses to develop health and wellness policies for students experiencing traumatic events utilizing therapy canines within the K-12 school setting.
• Evaluation Methods: This study, funded by the 2020 CNS Institute grant, employed a quasi-experimental design with three data-points (pre-, post- and follow up at 6 months), to assess educational content and learning related to AAT interventions within the K-12 school system. The educational intervention was based on the School Counselor and School Nurse Collaboration Model.  The Continuing Professional Development Reaction questionnaire was chosen for this study to evaluate professionals’ behavior in a K-12 school setting, specifically focusing on how knowledge translates into practice. This instrument was designed with intent to be used with different models or theories that focus on behavior change. 
• Outcomes: Data collection among 160 participants for the pre-intervention was in-progress at the time of abstract submission with follow up questionnaires scheduled immediately post-educational session. Analysis will occur fall 2020 with outcomes presented at the National Association of Clinical Nurse Specialist annual conference.
• Implications: Researchers will explore the benefits of the CNS role in the K-12 school setting to facilitate collaborative AAT efforts by both the school nurse and school counselor.  In addition, the impact AAT has on this collaboration when recognizing childhood trauma in the K-12 setting.

 

Role of CNS in Diversity and Inclusion
Interprofessional Collaboration
Other

In Resurging the Clinical Nurse Specialist Role, the CNS needs to look beyond the traditional environment and approaches to providing care.  At NACNS 2020, I spoke of a variety of ways that a CNS could be more active and visible and hence ultimately growing the role.  Our world has drastically changed since then.  I did not give up on what I believed there were ways for a CNS to function, and began an initiative called The Collective View.  The journey has been a learning experience for myself from several different aspects.  I would like to share the experience and point out how CNS qualities and characteristics have benefited this project. In addition, taking what I have learned and sharing it to other CNS’s with similar initiatives that will allow for growth of the CNS and a resurgence. 

 

My project has been called The Collective View.  We provide talks on social media that demonstrate a mental and physical health connection. There was always a dream and a vision, but moving forward  it was a big step;  and took some focused discussions to define the purpose.  By having this set-in place, it provided the flow of our project to be cohesive and engaging to all involved.  CNS qualities of providing compassionate care, being a patient advocate were core contributions to the design.  Being genuine and authentic was also key to representing the CNS.  Additional details were worked through during this phase.

 

The inspiration to move forward with  a business model was decided as individual time and contribution continued to build.  Research and collaboration were also very key in this phase.  Collaboration from other disciplines outside of nursing, and healthcare were vital.  Recognition of an integrative approach made the process cohesive. 

 

Moving forward we have learned from our work and occasional mistakes; AKA learning opportunities! Our confidence has gained momentum as  we move forward; we believe in our success and harmonious future.  This experience  has allowed for a level of creativity and  recognition to evolve and develop for all disciplines inspired by the CNS model.

 

CNS Improving Outcomes
Interprofessional Collaboration
Other

In the past couple of years there has been in increase in the number of students in the Clinical Nurse Specialists (CNS) tract at this university. This increase is an example of the desire for a resurgence of the CNS role.  In order to increase the numbers of Clinical Nurse Specialists, educational programs must be able to provide optimal educational experiences for students to demonstrate competency and further demonstrate the need for the role.

In 2020 as a result of COVID 19, Clinical Nurse Specialist Graduate Programs faced many problems associated with meeting all of the clinical requirements for students.  Many institutions resorted to complementary strategies to meet the essential requirements of a CNS program. The use and effectiveness of simulation with standardized patients in undergraduate and graduate nursing education programs is well documented. The literature was reviewed, and it was determined that there were limited scenarios that would demonstrate competency for a CNS in all three spheres of impact. Students are often comfortable in the patient and nursing spheres but with limitations in clinical experiences they may not have the opportunity to practice in all three especially the organizational or systems sphere. With the assistance of the Simulation Center Faculty and Staff, five case scenarios were developed and implemented via Zoom during the COVID lockdown period.  The cases utilized Standardized Patients to portray roles of various hospital personnel including risk management, nurse managers, and case managers. The program was evaluated utilizing student, faculty and Standardized Patient feedback. This presentation will discuss the development, implementation and the outcomes of the simulation experiences for CNS students

CNS Improving Outcomes

Reducing Catheter-Associated Urinary Tract Infections (CAUTIs) is a goal in every organization. Unfortunately, there is no magic bullet! Collaboration within and across disciplines, especially between nursing and physicians, is a key strategy to communicate the value, goal, and specific initiatives that ultimately affect the outcome to reduce CAUTIs. A clinical nurse specialist (CNS) is pivotal in this work. This presentation highlights how the involvement of a CNS can influence outcomes in an organization that has had its own resurgence of the CNS role within the last two years!  

 

CNS Improving Outcomes
Quality Initiatives
Interprofessional Collaboration

A new patient population with pulmonary artery catheters (PACs) was introduced to a progressive cardiac unit. Central line (CL) days increased from 1544 to 2688 and central line associated blood stream infections (CLABSI) increased to 1.86. 

Clinical Nurse Specialist (CNS) identified an opportunity to elevate nursing professional practice to improve quality of patient-centered care and patient safety, through evidence-based central line bundle adherence and dressing inspection. The team consulted with interprofessional collaborative partners, nursing experts, clincial nurses (CNs) at all levels, and partnered with patients and families. The engagement of all individuals made a pivitol improvement in infection prevention.

A multipronged, multidisciplinary nurse driven rounding process was designed to critically assess dressing placement, quality of catheter insertion site, communication between nurses, providers and patient education. This resulted in rounding on all patients with a CL three times a week under the guidance of the CNS and internal experts. Peer feedback and mentoring was provided in real time to CNs and through a weekly email with visual examples of CL dressings that were compromised. The email promoted autonomy as it provided rationale for how the integrity of CLs were compromised, and tips for interventions to implement.

Nurse driven rounds decreased CLABSI to 0.0  despite continued increase in CL days. Sharing knowledge and real time learning with colleagues increased CNs autonomy as they were able to independently identify when a CL dressing needed changing. Of the 1,071 CLs assessed 265 (24.7%) of the dressings required immediate interventions due to compromised integrity. The team partnered with patients during rounds providing education on the importance of CLABSI prevention. Patient satisfaction outperformed in 14 of the 16 domains and met the magnet standard, “communication with nurses” in the 99^th percentile, which can be attributed to CL rounding and patient education.

Nurse driven evidence-based practice CL management and standardized rounding resulted in improved patient outcomes. Engagement of CNs and patients ensures continuity of care in the clinical practice setting. This process can be individualized to any care delivery system and is budget neutral. 

 

CNS Improving Outcomes
Interprofessional Collaboration

Purpose: This process improvement project was implemented to decrease unnecessary or inappropriate dispensing of Z-Flo Fluidized Positioners.

Relevance/ Significance: Use of Z-Flo Fluidized positioner is an essential component of hospital-wide pressure injury prevention bundle for all patients with Braden score ≤18. Due to this, some patients determined low risk for pressure injury based on ability to self-position, ambulate appropriately within two to three days and have shorter length of stay have been ordered positioners inappropriately leading to unnecessary financial waste. Between August 2018 and May 2019, the hospital spent $437,000 on Z-Flo Fluidized positioners.

Strategy and Implementation:  A multidisciplinary taskforce, led by the Clinical Nurse Specialist,  for waste reduction was created and using a Lean Six Sigma methodology, the DMAIC principle (Define, Measure, Analyze, Improve, Control), created an evidence-based algorithm for decision-making prior to ordering the positioners a collaborative approach to waste reduction. Education provided to nursing and central supply staff on the inclusion criteria and the use of a checklist as part of the ordering process. To ensure compliance, central supply monitored department usage monthly and presented to taskforce members.

Evaluation/Outcomes:  Pre-implementation positioner expenses from January to June 2019 was $236,909 and post-implementation expenses from January to June 2020 was $76,146, a 68% reduction and total savings of $160, 763. Furthermore, HAPI Stage II and above (excluding device-related) was monitored to ensure quality outcomes were not compromised. The number decreased from 4 in January to June 2019 to 3 in January to June 2020.

 

Implications for Practice: Simple cost-saving processes can lead to substantial reductions in costs while maintaining high levels of quality.

 

 

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives
Interprofessional Collaboration

Background

In a time of increasing public transparency and resulting competition within and between healthcare systems to achieve public recognition from accreditation and quality organizations, individual metric performance is often assigned to a single discipline. Unfortunately process and outcome measurements in the hospital environment are often influenced by the processes and workflows of interdisciplinary team members. 

In response to changes in the pain management standards introduced by The Joint Commission in 2018, a large University Medical Center with two acute care hospitals developed a process metric to monitor nursing compliance with matching dose of analgesic administered with numeric pain rating indications. Several attempts were made to address nursing compliance with this metric with lack of sustained improvement beyond 70%. Physician ordersets were identified as a key root cause by nursing but the team was reluctant to consider changes to them as this option would require extensive work by pharmacy, physician, informatics and nursing stakeholders.

Evaluation methods

The pain management Clinical Nurse Specialist proposed and completed a cross sectional analysis of the variation in the current state of analgesic orders using Six Sigma methods. Active analgesic orders from 5 medical surgical units were evaluated for presence of errors defined by the system’s Pain Management Steering Committee’s interdisciplinary stakeholders.

Outcome

Analysis of 130 charts for medical surgical patients with active analgesic orders yielded 76% error rate and variation at the 1.9S level. Based on results the interdisciplinary stakeholders determined the analgesic ordersets would need to be addressed to ensure nursing success in complying with the dose to score metric. The team investigated different options and through newly established collaboration with the larger university health system, identified a solution for pilot to address the identified root cause.

Implications

Highly reliable organizations reject oversimplified explanations for problems and seek to effectively uncover root causes for chronic underperformance for key metrics. Improvements in these systems are aimed at identifying failure points and mistake-proofing processes instead of simply attributing problems to individual non-compliance. Six Sigma methods focused on quantifying process variation, can help provide a compelling argument to address root causes directly impacted by the workflows of other disciplines that may be otherwise resistant to change.

CNS Improving Outcomes
Quality Initiatives
Patient Populations
Interprofessional Collaboration

Title: An Interdisciplinary Approach to Decreasing CAUTI in Persons with Spinal Cord Injury in Acute Rehabilitation

Author(s): Shelly Amato PhD, APRN-CNS, CRRN, CNRN, Bridget Blayney BSN, RN, CRRN and Christina V. Oleson MD

Significance/Background: Urinary tract infections (CAUTI) are the fifth most common healthcare associated infection (CDC, 2020). Reducing CAUTI is even more challenging in persons with spinal cord injury (SCI) due to neurogenic bladder, resulting in retention of urine and the inability to empty the bladder (Taweel & Seyam, 2015). Historically, indwelling catheters were used to manage neurogenic bladder but have been found to increase the likelihood of developing a CAUTI (Barboglio Romo et al., 2018).

Project Description: An interdisciplinary quality improvement project was initiated to decrease CAUTI rates and indwelling urinary catheter (IUC) use on a SCI rehabilitation unit. The project involved implementation of a catheter removal algorithm, urine culture stewardship, and staff education. The algorithm outlined a step by step approach to IUC removal. Day 1 & 2 included physician assessment of contraindications to the intermittent catheterization program (ICP), monitoring intake and output, and limiting fluids to a maximum of 2 liters per day. In addition, family were identified for education about the ICP. Days 3 & 4 included discontinuing the IUC and initiating the ICP with bladder scanning to determine timing of the ICP.  

Evaluation Methods: CAUTI rates were calculated based on CDC National Healthcare Safety Network (NHSN) definitions.  Urinary catheter days were calculated based documentation in Quadramed. 

Results: CAUTI rates decreased from 7 (3.85/1,000 catheter days) in 2017 to 1 (3.09/1000 catheter days) in 2018 to 0 in 2019 and 0 through July 2020. Catheter days decreased from 1817 in 2017 to 510 in 2018 to 331 in 2019 and 109 through July 2020.

Conclusion: The implementation of a urinary catheter removal algorithm, urine culture stewardship, and staff education has shown to be a sustainable practice change that has decreased the rate of indwelling urinary catheter use and nosocomial CAUTI rates for patients with SCI in the inpatient rehabilitation setting.

Barboglio, P.G., Smith, C.P., Cox, A., Averbeck, M.A., Dowling, C., Beckford, C., Manohar, P., Duran, S., & Cameron, A.P. (2018). Non-surgical urologic management of neurogenic bladder after spinal cord injury, World Journal of Urology, 36, 1555-1568.

Centers for Disease Control. (2020). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI] and other urinary system infection [USI] events. Retrieved from https://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

Taweel, W., Seyam, R. (2015). Neurogenic bladder in spinal cord injury patients. Res Rep Urol, 7, 85-99.

 

CNS Improving Outcomes

Adherence to CPGs diminishes when providers lack awareness, knowledge, resources, or structural support (Fisher et. al, 2016). Successfully implementing CPGs into practice involves finding strategies to overcome existing barriers. At a large acute care hospital, emergency department (ED) providers had varying levels of unfamiliarity and exposure to BFE guidelines. Tailored interventions catering to ED providers (e.g. physicians, residents, and advanced practitioners) were needed to help them correctly implement BFE procedures and reduce patient care fallouts. 

The purpose of this project was to increase provider adherence to BFE guidelines by 1) revising the BFE procedures to a more accessible, user-friendly version and by 2) providing education sessions to raise awareness.

Role of CNS in COVID-19 Pandemic

When COVID-19 presented in the United States in early 2020, healthcare organizations scrambled to take necessary precautions to keep staff and patients safe. Guidance from local health departments and the Centers for Disease Control was somewhat sparse and rapidly evolving in the early stages of the pandemic. The sole clinical nurse specialist (CNS) for a large ambulatory cancer center assumed a unique and multifaceted role in COVID-19, focused on maintaining staff and patient safety by utilizing the most up-to-date guidance and evidence.

Initially, the CNS focused on rapidly training and validating staff on proper application and use of COVID-19 appropriate personal protective equipment (PPE) through hands-on sessions. Quickly, to ensure patient safety, the decision was made to open an oncology specific COVID clinic in a location separate from the cancer center, staffing with a core group of nurses, nurse practitioners (NPs), and medical assistants. The CNS was essential to the day-to-day operations of the clinic including coaching staff on proper care and testing procedures, collaborating with nurses and NPs in coordinating patient care, and advocating for the necessary supplies and equipment.

The oncology COVID clinic was open six days per week for seven weeks from March 30 to May 8. During that time, the clinic tested 356 patients utilizing rapid point-of-care testing. 25 patients tested positive, resulting in a 6.8 percent positivity rate. The CNS was present in the clinic for 75 percent of operating hours and observed 75 percent of instances of staff donning and doffing PPE. For observed instances of gaps in practice, just-in-time corrections were made by the CNS. As a result, zero percent of staff working in the COVID clinic experienced symptoms or tested positive for COVID-19.

COVID-19 came fast and furious, without a playbook. Guidelines were ever-changing; however, the CNS stayed up to date with best practices and was a key communicator of changes in guidelines to the frontline staff. The rapid and proper training of staff and day-to-day clinical support by the clinical nurse specialist allowed for the safe care of patients and protection of staff.

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Title: A Clinical Nurse Specialist Led Diabetes Self-Management Intervention

Significance & Background: Individuals with diabetes are two times more likely to suffer from a stroke, with elevated blood sugars associated with micro- and macrovascular complications and risk of recurrent stroke.  Ninety-one percent of stroke risk is attributed to modifiable risk factors, and in terms of hyperglycemia, 50% of individuals with diabetes have suboptimal glycemic control.  Diabetes self-management education and support (DSMES) interventions are associated with improved glycemic control and fewer micro- and macrovascular complications.  Despite this knowledge, less than 10% of individuals with diabetes participate in these programs.  In many instances, the impact of stroke in terms of modifiable risk factors and disease burden is not well addressed during hospitalization resulting in significant gaps in care management.  Additionally, stroke often requires family support to help manage the condition.  The purpose of this project is to design and implement an evidence-based intervention to improve diabetes self-management behaviors in patients who suffered a stroke at Midwestern Level 1 trauma center, and teaching hospital. Currently the clinical nurse specialist (CNS) provides diabetes teaching for the stroke team, but the consultation process is not well-structured or utilized. 

Evaluation Methods: (In progress)  The intervention for this project is a structured DSMES consultation intervention based on evidence-based guidelines. The intervention will be implemented over the course of twelve weeks using the Individual and Family Self-Management Theory as a framework to guide the consultation intervention.  Using a screening algorithm, the CNS will screen stroke patients with diabetes or their designated caretaker for the consultation intervention.  Validated tools to assess baseline diabetes knowledge (KNOW Diabetes Test) and diabetes self-efficacy (Diabetes Empowerment Scale-Short Form [DES-SF]) will be administered prior to receiving the DSMES consultation and after discharge. 

Outcomes: (In progress) Diabetes knowledge and self-efficacy will be evaluated prior to the consultation and once the patient discharges. Additionally, satisfaction with the intervention will be evaluated after discharge using a survey.  Consultation data will also be collected and include: patient age, type of stroke, type of diabetes and whether a new diagnosis, length of stay, time to complete consultation in minutes, date of discharge, recipient, type of follow-up, follow-up attempts, a post-discharge patient satisfaction survey, and 30-day readmissions if available. 

Implications: (In progress) Overall, the aim of this project is to improve and standardize the current DSMES consultation using evidence-based practice.  The results of this project will also provide valuable data to improve and potentially support expansion of the current CNS consulting process.

CNS Improving Outcomes
CNS as Researcher
CNS as Project Manager
Role of CNS in COVID-19 Pandemic
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Significance & background: Clinical Nurse Specialists are extremely valuable healthcare team members that may be underutilized in times of crisis. This case study examines how the role of the clinical nurse specialist proved worthy and evolved to meet the demands of the COVID-19 pandemic as it impacted one rural hospital in the southern United States of America. Evaluation methods: This reflective process delineates the actions taken and daily activities of the CNS role from the perspectives of the healthcare system, project management, patient populations, analytics, research activities, direct care, epidemiology, and leadership during this novel experience.  Outcomes: The outcomes of the CNS activities are a work in progress and will be available by the time of the presentation. Implications:  The implications of sharing this information to view opportunities for CNS and their respective organizations to think about and possibly apply the CNS differently going forward.

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives

Collecting patient satisfaction data can be challenging. Figuring out the best we to administer a patient satisfaction survey including timing and administation methos can very. We attempted to survey Palliative Medicine patients that visited our clinic either in person or virtually. Our goal was to figureout what administration process worked best for our staff and patients. 

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Title:  Improving door to antibiotic times for septic pediatric patients that present to the emergency department

Background: Sepsis remains a leading cause of pediatric mortality. Antibiotic administration within an hour of identification of sepsis and septic shock has shown to improve outcomes for pediatric patients.  Our children’s hospital implemented a sepsis screen for early recognition and treatment of patients at risk for sepsis in the emergency department. Abnormal vital signs, skin color, capillary refill, and history of high risk conditions trigger an alert prompting a huddle at the patient's bedside with the attending physician, charge nurse, and bedside nurse.  After the huddle, patients deemed high risk for sepsis are placed on a sepsis pathway, which is a combination of diagnostic tests and early goal-directed therapy. We found that our door to antibiotic administration within 60 minutes improved from 76 %to 93% after our implementation of a sepsis tool in the EHR and standardizing our response process. 

Methods:  After identifying our current state through a retrospective chart review of patients that should have received antibiotics within 60 minutes, the PDSA (plan, do, study, act) methodology was used for gap analysis that identified we did not have a standard process or outcome measures to achieve the 60-minute time goal of antibiotic administration for pediatric septic patients.  The following metrics were used for our sepsis improvement initiatives; identification of sepsis to antibiotics, time of identification of sepsis to ED team huddle, time for provider orders to be placed, time to IV established, and antibiotic order to antibiotic delivery time. 

Hypothesis:

1.      If we send out an ever bridge page as a huddle trigger, then we expect one process for sepsis awareness

2.      If we require physicians to enter orders within 15  minutes of receiving ever bridge page, then we expect orders to be placed within 15 minutes

3.      If we create an infographic of the ED sepsis process inclusive of times for staff on a weekly basis, then we expect everyone to have a shared understanding of expectations related to improving door to antibiotic times

4.      If we create a process around sepsis IV starts, then we expect an IV to be placed within 30 minutes or IM antibiotics to be administered

Results:

Number of patients put on the sepsis pathway: 70

Percent of patients that received a sepsis huddle: 87.14%

Medium time of huddle from sepsis alert: 00:02

Medium time to antibiotic order: 00:01

Percent of antibiotics given in less than 60 minutes: 93.85%

Conclusion: Identification and team-based decision support through the use of an EHR screening tool and standardized treatment interventions are important for improving door to antibiotic times within 60 minutes for septic pediatric patients in the emergency department. Future research would look at cost savings and decreased length of stay for patients that received antibiotics within an hour compared to those who did not.

 

Quality Initiatives

please see below

CNS Improving Outcomes

Emergency Department (ED) overcrowding is a systemic problem in the U.S., leading to delays in care and increased morbidity & mortality. The National Emergency Department Overcrowding Score (NEDOCS) is a validated scoring tool to accurately assess the severity of ED overcrowding through objective measures of ED and inpatient bed status, current ED patient volume, and current ED length of stay. Early recognition of worsening ED overcrowding may be used to proactively manage ED throughput by reducing delays in inpatient admissions and diagnostic studies, and identifying a need for additional ED staff. In conjunction with the NEDOCS calculation, a collaborative decision support tool to improve communication of the ED-to-inpatient admission process may be effective at reducing ED overcrowding and improving patient throughput.

A decision-support matrix, based on an objective measure of ED overcrowding, was implemented to reduce inpatient admission times, reduce delay in ancillary support for ED patients, and direct recall of additional ED staff. The ED Charge Nurse conducted a NEDOCS calculation every two hours to determine crowding status. Upon escalation of ED overcrowding, the in-house nursing supervisor would actively manage inpatient bed status to minimize admission waiting times. Additionally, ancillary support services would be asked to expedite diagnostic studies, and on-call ED staff would be recalled if it were determined that staffing shortage was impacting patient flow. To improve staffing, critical care nurses cross-trained to the ED and would augment the ED staffing when available, thus reducing the need to activate the on-call nurse. Pre and post comparison of NEDOCS scores, patient volume, and ED time to admission were evaluated.

Throughout this 18-week period, the average NEDOCS value per week remained constant, despite the fact that the average patient volume at the time of the NEDOCS calculation increased by 36.3%. Additionally, the median time from decision-to-admit to patient disposition decreased by 48 minutes. Furthermore, the increased collaboration between the ED charge nurses, the nursing supervisor, and the critical care nurses resulted in a more supportive working relationship.

The ability to identify and quantify overcrowding is an important aspect of managing the flow of patients in the ED. Reducing overcrowding in the ED requires a collaborative approach in order to be effective. Reducing overcrowding in the ED results in the ability to provide more timely care to patients with urgent or emergent needs.

Quality Initiatives
Interprofessional Collaboration

The purpose of this quality improvement project was to evaluate the impact of twice a day BMAT patient mobility assessments conducted by nursing and a creation of a subsequent mobility plan on the percentage of full census days with out of bed activity as well as patient satisfaction scores and certain hospital-acquired conditions and complications. Pre and post-data was collected including the percentage of full census days with out of bed activity, length of stay, patient satisfaction scores as well as incidence of inpatient HAPIs, falls, hospital-acquired pneumonia, and deep venous thrombosis. Data was collected retrospectively by an independent data abstractor. Data was collected 3-months prior to the initiation of the project as well as monthly after the project had been initiated for one month. Results included an increase in full census days with out of bed activity, no change in the incidence of HAPI, a decrease in patient satisfaction scores, an increase in total falls per 1,000 patient days, and no change in hospital-acquired pneumonia or deep venous thrombosis cases. Considering the ongoing COVID-19 pandemic, it is important to note that results of this project could have been impacted by staffing changes, visitor restriction policies, and other measure put into place to work through the current pandemic. Additional inquiry would be helpful regarding the impact of mobility on other hospital acquired conditions as well as the tie between mobility and discharge disposition.

 

CNS as Project Manager
Quality Initiatives
Capture Value of the CNS
Interprofessional Collaboration

The role of the CNS is multidimensional lending itself to project management. To effectively manage a project you need to recognize the micro and macro system effects, which relate to the patients, nurses, and leadership when developing a new nursing team. The development of our hospital vascular access team (VAT) began at our Associate Vice President level who then developed a task force with a vascular access staff nurse and myself, the CNS. As the CNS, I oversaw all training and orientation developed, mentorship for leadership in the staff nurse, as well as the footwork of in servicing with the product company and VAT nurses. To ensure buy in there was multidisciplinary teamwork with physicians and APPs and numerous presentations to leaders across the hospital.

In 2018, our medical center identified an increase in patient length of stay (LOS) related to increased wait time for placement of an appropriate vascular access device (VAD). LOS is historically attributed to an increase in hospital-acquired infections (HAI) and increased mortality rates¹.  Increased LOS also results in less available beds for other patients especially during times of peak hospital census. Avoidable days totaled 70 avoidable business days over July 2018-October 2018

In addition to LOS, each peripherally inserted central catheter (PICC) placement performed with fluoroscopy in Interventional Radiology (IR) resulted in radiation exposure for the patient. Leading to unnecessary radiation exposure for PICC patients.  VAT uses ECG tip confirmation for placement to improve patient safety and decrease radiation exposure compared to IR. Additionally, patients who returned with dislodged or malfunctioning lines had to wait for IR services availability to replace line.

Central Line Associated Blood Stream Infection (CLABSI) rate was higher than the desired goal at medical center during fiscal year (FY) 2019, with the targeted goal of a CLABSI Standardized Infection Ratio (SIR) of 0.74.

Per the Infusion Nurses Society “a designated infusion team decreases infusion related complications and related costs and increases patient satisfaction”². In an attempt to improve patient safety, decrease CLABSI and LOS we created the VAT.

Since creation, the VAT has also started daily rounding on their lines utilizing standard work practices created by a VAT nurse and CNS to ensure care and maintenance is meeting the most current evidenced based practices. This also provides the bedside nurse an opportunity to follow up on any questions, concerns, or learning opportunities with a VAT RN to improve their patients care and outcomes.

For FY 2020 the VAT consulted 1,382 patients, placed 1,003 lines, has had an overall success rate of 96.9%, decreased overall radiation exposure by 88.7% as well as has attributed to zero avoidable LOS days. The medical center also successfully decreased their SIR for FY 2020 even in the wake of COVID-19 pandemic.

 

• Weiss AJ, Elixhauser A. Overview of Hospital Stays in the United States, 2012: Statistical Brief #180. 2014 Oct. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK259100/

 

• Infusion Nurses Society,. (2016). Policies and procedures for infusion therapy.
• Gorski L, Hadaway L, Hagle, ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016; 39 (suppl 1): S1-S159.

 

• Girgenti, Constance & Moureau, Nancy. (2013). The Need for Comparative Data in Vascular Access: The Rationale and Design of the PICC Registry. Journal of the Association for Vascular Access. 18. 219–224. 10.1016/j.java.2013.07.003.

 

 

Patient Populations
Other

This lecture will cover a review of the current data surrounding cannabis regarding symptom management, including review of the different cannabinoids and the different forms of administration. We will also cover a review of the pharmacokinetics and pharmacotherapeutics of medicinal cannabis and how it interacts with the endocannabinoid system. Finally, we will discuss the legal side of cannabis and recommendations and position statements from nationally recognized agencies.

CNS Improving Outcomes
Quality Initiatives
Patient Populations
Capture Value of the CNS
Interprofessional Collaboration

Background/Significance: At the end of life, most individuals would prefer to pass at home or in hospice. Many hospitals are unaware of individual patient preferences and admit patients expected to pass in <48 hours via the Emergency Department (ED), thus disabling their terminal wishes. The aims of the project were to better honor patient preferences by ascertaining end-of-life wishes, develop a process for implementation, and to reduce overall inpatient mortality.

 

Evaluation Methods: Using Lean methodology, this interdisciplinary group used a structured process to define the problem, review patient trends, design an approach, and develop key drivers and indicators of success. Facilitated by a Value Improvement Consultant, the seven-member core team included Unit-Based Medical Directors (UBMDs), Patient Care Managers, and Clinical Nurse Specialists (CNSs) from two Medicine units, and a Manager of Care Coordination (MCC). Additional support included providers from Hospital, Palliative, and Emergency Medicine teams. Chart reviews by UBMDs illuminated opportunities to better anticipate patient outcomes and identify future imminent cases. The interdisciplinary group collaborated to develop a “Code Goals of Care” process that included CM patient screening on arrival to the ED, refined hospice transfer pathway, and chart flag to alert Providers of patient wishes for any future admissions. A secondary aspect of the pathway was a unit-based CNS screen of inpatient admissions and collaboration with the MCC for chart flag inclusion of patient wishes prior to future admissions. Patients were included in the project if they were in the ED with estimated survival <48-hours, or inpatients with Comfort Care/Do Not Resuscitate orders or expressed desire for hospice care. During the early months of implementation, a weekly huddle was setup to review cases and pathway activations to ensure the process was working well.

 

Outcomes: In the initial four-month project time, 59 patients were transferred to hospice, better supporting their care wishes. A 41% reduction in Inpatient mortality was seen, reducing from 3.0% to 1.73% in the same timeframe. By the end of data collection at 8 months post-implementation, 116 hospice transfers had been initiated, and inpatient mortality reduction was sustained at 1.9%.

 

Implications: Most people would rather pass at home or in hospice, not in the hospital. By ascertaining patient end-of-life wishes, collaborating with ED Providers and CMs, and screening inpatients for care goals, this interdisciplinary team was able to effectively enact and sustain patient preferences and reduce inpatient mortality rates. Comprehensive care maps involving Providers, Nurses, Case Managers, and Care Coordinators are critical to ensuring adherence to patient wishes and limiting unnecessary inpatient admissions. Future projects would include increased involvement of Primary Care Providers, earlier conversations with patients regarding end-of-life preferences before the need arises, and having an enactment plan in place.

CNS as Project Manager

Title

Integrating Psychiatric Technicians into a Medical Emergency Department: A CNS led project

Significance & Background

It is well known that the United States is experiencing a mental health crisis. Between 2006 and 2013, there was a 55.5% increase in emergency department (ED) visits for depression, anxiety, and stress reactions (Weiss, et al., 2016). This creates a strain on the mental health system and the local emergency departments who are providing care in an acute mental health crisis. While all nursing students receive basic education on caring for a patient with a mental health disorder or in an acute crisis, emergency department nurses were placed in the unique situation of caring for this population for a prolonged length of time. A review of visits to a community hospital revealed an increase in patients presenting for a mental health evaluation, length of stay for this population, and instances of workplace violence. The leadership was ready to implement changes to keep the teammates safe and improve the care for the mental health population.

In 2018, we experienced 85 workplace violence instances in the ED, or an average of 7 per month. The leadership of the healthcare system was looking for a way to decrease the number of instances of violence toward the teammates. Additionally, we were seeking a way to provide better care to our increasing mental health population. An interdisciplinary team was formed to review a potential new position: a psychiatric technician. We hypothesized that adding an experienced psychiatric technician to the ED team could decrease the length of stay and increase the percentage of patients we could discharge to home because of earlier therapeutic interventions. We additionally hypothesized that the psychiatric technician could decrease the amount of time a violent patient would need to remain in restrictive interventions because of their unique training with therapeutic communication.

In August 2019, hospital leadership approved for the Emergency Department to hire 5 full time psychiatric technicians to cover the shifts 24/7. We borrowed an experienced psychiatric technician from a psychiatric hospital within our healthcare system and utilized their nursing educator to assist with and onboarding plan. The Clinical Nurse Specialist (CNS) for the Emergency Department worked to outline the project timeline, create an onboarding strategy, and develop metrics to monitor for program success.

Evaluation Methods

The team gathered and reviewed 10 potential metrics to monitor. After the CNS gathered baseline data, determined a secure locate to retrieve the data, and presented potential goals to the interdisciplinary group, five final metrics were identified.

1. Decrease workplace violence
2. Increase teammate perception of safety in the Emergency Department
3. Increase/Maintain non-BH patient perception of safety while seeking care in the ED
4. Increase percentage of BH patients discharged to “home”
5. Decrease average time in violent restraints

Teammates were surveyed on feelings of safety and security, pre-implementation and monthly for 3 months during the pilot. Length of stay, disposition, and restraint data were gathered from a review of relevant electronic medical records. Workplace violence data was gathered from the hospital security team who reports these on a monthly basis.

Outcomes

During the three-month pilot project, there was a decrease in workplace violence instances and length of stay. The teammate perception of safety, patient perception of safety, and average time in restrictive interventions were not affected.

The most impressive outcome from the pilot was the decrease in workplace violence. We experienced a 9.4% decrease in reported instances in 2019 compared to 2018. During the pilot period alone (Q4 2019), there was 28.5% reduction in in reported instances in Q42019 compared to Q42018.

Due to the decrease in workplace violence and the positive feedback from the teammates (both nursing and psychiatric technician), an additional emergency department within the healthcare system adopted the program and has begun integrating psychiatric technicians into their teammate mix.

Implications

Integrating psychiatric technicians into a medical emergency department can help decrease violence in the department, alleviate some of the stressors associated with caring for a difficult patient population, and decrease the LOS by starting therapies early. The mental health population needs a different type of intervention compared to the traditional ED patient. Adding psychiatric technicians to your ED teammate mix can help provide population specific care.

 

Reference:
Weiss, A.J., Barrett, M.L., Heslin, K.C., & Stocks, C. (2016, December). Trends in Emergency Department Visits Involving Metal and Substance Use Disorders, 2006-2013. Healthcare Cost and Utilization Project. https://hcup-us.ahrq.gov/reports/statbriefs/sb216-Mental-Substance-Use-Disorder-ED-Visit-Trends.pdf

Quality Initiatives
Patient Populations
Interprofessional Collaboration

This presentation describes the CNS role in an interprofessional team charged to improve organizational practices for patients with opioid use disorder.  Various strategies including nursing and patient education, use of Clinical Opoid Withdrawal Scale, electronic medical record enhancements, and linkage to community resources will be discussed.  

CNS Improving Outcomes
CNS as Project Manager
Role of CNS in Diversity and Inclusion
Patient Populations
Interprofessional Collaboration

See My Suffering: Utilizing the DisDat ™ Tool to Identify Suffering in Developmental Delay

Jeannette (Jeannie) Meyer, MSN, RN, CCRN-K, CCNS, PCCN-K, ACHPN

Mary Beth Chambers, DNP, RN-BC, ACNS, ACHPN

Grace Sund, RN, MSN, CPNP, CPHON

 

Background: Evidence- based pain scales such as FLACC™, Pain AD ™ and CPOT ™ are often utilized to assess pain and guide treatment for adult and pediatric patients who are unable to communicate verbally. However, such scales may not be the best assessment tools for patients with Developmental Delay (DD), whose manifestations of pain and discomfort may differ from most nonverbal individuals.  DisDat ™ captures individual manifestations of pain for each patient and allows for those manifestations to be readily available by healthcare providers. DisDat ™ is completed by the caregiver most familiar with the adult or child with DD. The need for the DisDat ™ was identified in both the adult and pediatric populations at an Academic Medical Center.

Objectives:

• To support the moral agency of interdisciplinary team members in the delivery of patient centered pain management for the DD population admitted to the inpatient setting.
• Anticipate the need for specialized assess method for individuals with Developmental Delay

• To design and implement a reliable process supporting the completion of DisDat ™ for patients diagnosed with DD to improve communication and staff recognition of patient specific pain behaviors.

Methods: A palliative care led multidisciplinary team including stakeholders from pediatrics, adult and psychiatry outpatient and inpatient settings convened over the course of a one-year period to pilot and explore methods for implementation of the DisDat ™. A pilot of the tool was tested on one pediatric unit in collaboration with the outpatient long term care facility for these patients over a period of 9 months. Additional DisDat ™ tools were completed for adult patients with DD receiving care from by a Palliative Care physician team member. Copies of the DisDat ™ were made available to caregivers; a copy of the all-inclusive first page of the DisDat ™ was posted at the patient’s bedside for easy referral.

Results: 6 patients had baseline data completed using DisDat ™.  The DisDat ™ was positively received by hospital staff and the long-term care facility that integrated the tool into their Admission process.

Conclusions: Based on the low volume results and understanding that these patients can be admitted to multiple services and locations throughout the healthcare system, the team designed a reliable system wide implementation strategy for high-risk-low-volume patients using lean methods. The process includes DD diagnosis data capture in the EMR on admission triggering an automatic page to Clinical Nurse Specialists (CNSs). CNSs will facilitate completion of the form and offer just-in-time education to staff caring for DD patients. ICD 10 codes have been identified and the build for the automatic trigger is in process pending system wide roll out. Completed forms will be located in the advance directive section of the EMR.

Implications for Practice: Individuals with DD until this time have lacked a discomfort assessment tool that would provide access to their individual manifestations. DisDat ™ offers an opportunity to more appropriately meet the pain and discomfort management needs of this high-risk-low-volume population.

 

CNS Improving Outcomes
CNS as Project Manager
Patient Populations
Other

The rapid expansion of the use of telehealth in the United States due to the pandemic has accelerated the need for CNS to demonstrate new  additional competencies. Understanding the use of this new technology in clinical practice will include demonstrating the skills needed to incorporate telehealth into the healthcare system or facility where they work. Competencies in telehealth need to include increased knowledge of computer systems, and also how to ensure patient safety and satisfaction with quality of care. The Telehealth Workgroup of the NACNS Professional Development Committee was formed to develop a position statement on CNS Telehealth Competencies and ensure that CNS are ready to be leaders in the use of new technology in healthcare. 

CNS Improving Outcomes
Pharmacology
Patient Populations
Interprofessional Collaboration

Significance & Background: Increased narcotic use in surgery patients has contributed to the current national opioid crisis, extended length of stay, readmissions for inadequate pain control, and increased risk of complications. At a large academic medical center an interdisciplinary team adopted an Enhanced Recovery After Surgery (ERAS) protocol to mitigate risk of opioid addiction among thoracic surgery patients.

Evaluation Methods: An assessment of prescribing patterns and outcomes data drove the initiation of ERAS. Data revealed that the thoracic surgery service was the second highest prescriber of narcotics with an increase in epidural adverse events, inadequate pain relief, and pain-related readmissions. The ERAS protocol was implemented to improve patient pain management via opioid-sparing techniques and multimodal analgesia throughout the patient’s care continuum.

Outcomes: Content experts developed an algorithm, guiding providers and nurses on a collaborative stepwise approach in managing acute post-operative pain. The thoracic surgery clinical nurse specialist (CNS) collaborated with the thoracic surgery chief, nurse practitioners, pharmacist, nurse manager, and clinical nurse leads to educate nurses on administering, monitoring, and assessing side effects for each medication. Educational methods included multi-tiered in-services, “just in time” education, and huddles. Following implementation of the protocol, epidural adverse events were eliminated; 80% of patients were discharged on Tramadol with zero pain-related readmissions.

Implications: The CNS, along with interdisciplinary team members, plays a vital role in the successful and sustained adoption of ERAS protocols to improve patient safety and pain management.

CNS Improving Outcomes
CNS as Project Manager
Role of CNS in COVID-19 Pandemic
Interprofessional Collaboration

Often the CNS  leads the introduction of new therapies and equipment that require the integration of various clinical and non clinical departments . At a minimum a CNS is the change agent, leader , clinical expert and patient advocate. What is less recognized is the project management function of the CNS that has  a significant impact on an organizational level. This session describes the impact of the CNS as a project manager and includes examples of managing projects at a clinical , departmental and organizational level.

Patient Populations

Dementia is a neurodegenerative disorder that causes progressive cognitive decline and non-cognitive changes in behavior and social functioning. Dementia affects about 46.8 million people worldwide, and is estimated to triple by 2050 (Liang, Piroth, Robinson, MacDonald, Fisher, Nater, Skoluda, & Broadbent, 2017). Animal assisted therapy has been used since 2009 when caring for dementia patients, but due to the potential of allergies, injury, and fear of the animal, the use of this method brings concern. Consequently, robotic pet therapy is a viable substitute for animal therapy (Petersen, Houston, Qin, Tague, & Studley, 2016). The PARO robotic seal is an interactive, therapeutic robotic device that is designed to improve the mood, communication, behavior, and psychological symptoms of individuals with dementia (Dodds, Martyn, & Brown, 2018 and Shibata & Coughlin, 2014). This proposal will discuss the role of the Clinical Nurse Specialist as a researcher in relation to the use of robotic pet therapy and the level of anxiety of patients with a diagnosis of dementia in an acute care setting and fall rates.

Role of CNS in COVID-19 Pandemic

The increased demands on healthcare facilities as a result of coronavirus (COVID-19) have taken an emotional and physical toll on Healthcare Workers (HCW), who are on the front lines of patient care. HCW are at an increased risk of mental health disorders including depression, anxiety, and PTSD as a result of repeated exposure to traumatic events (secondary trauma), long working hours, workplace violence, and repeated exposure to death and suffering. A literature review was conducted and identified resilience interventions as a theme. Interventions identified were small group resiliency training, multiple intervention approach, structured debriefing, and peer to peer support. The purpose of this Doctor of Nursing Practice (DNP) project will be to implement a strategy to promote resilience and develop positive coping skills reducing anxiety, depression and improving emotional well-being in HCW. The Battle Buddy intervention consists of a structured process of peer to peer support. The Battle Buddy program is widely used by the U.S. Army and was recently implemented in the Hospital setting by the University of Minnesota as a response to the COVID-19 pandemic. The Anticipate, Plan, Deter (APD) model and strategies to promote resilience and emotional well-being will be made available to the participants. The intervention will be piloted in the college of nursing (CON) at a large Midwestern University and will include students enrolled in the Advanced Practice Registered Nurse (APRN) program. The intervention will be implemented in phases that include assigning Battle Buddy pairs, providing resources, and structured (optional) Battle Buddy Workshops. The well Being Index (WBI) will be used to survey the students pre implementation (baseline), 6 weeks following full implementation, and 12 weeks following full implementation (post).

Patient Populations

Title: Multimorbidity and Physical Activity in Heart Failure Patients

Background: Heart failure (HF) affects 6.3 million adults annually and exceeds costs of $30.7 billion.  Half of all HF patients suffer from concomitant conditions and frailty, as they are surviving and living longer with conditions due to medical advances.  Regular physical activity (PA) is a well-established research-driven guideline in HF patient management, although up to 91% of patients report physical symptoms as a primary reason for not engaging in PA.  The prevalence of multimorbidity in HF patients could be hypothesized to contribute to physical symptoms that deter PA in this population, affecting their quality of life (QOL) and outcomes.   Therefore, we hypothesize that  type and amount of multimorbidity is associated with lower PA in HF patients. 

Purpose: The aims of this project are two-fold: (a) to study and characterize multimorbidity in HF patients and their association with PA in a HF population from a previously conducted APRN-led RCT; and (b) to contribute to a larger body of PhD dissertation work that is ongoing by this author in the topic area of multimorbidity in HF.

Methods: Data analysis is currently underway using SPSS to explore characteristics of the HF patient population.  The data analysis in this project will be explorative and descriptive in nature, in order to characterize multimorbidity and its association with PA (measured by Actigraph data) in these patients based upon clinical (i.e., multimorbidity)  and non-clinical factors (i.e., socio-demographic).

Results:  Data analysis in progress.  Descriptive data and any associations to be presented.  

Implications: Heart failure is a leading cause of hospital readmission for adults over the age of 65, impacting healthcare utilization, costs, and quality of life for this vulnerable population.   Collection and analysis of patient attributes in  the HF population has the potential to identify actionable areas for interventions by APRNs that improve patient QOL and outcomes and reduce readmission rates or healthcare utilization.  In addition, this endeavor will provide data for future research in risk stratification for functional vulnerability in HF patients.

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives
Patient Populations
Capture Value of the CNS

Objective: Implement neurosurgical standard of care post-operatively for nurses to follow, with a focus on early removal of indwelling urinary catheters (IUCs) and ambulation, to improve post-operative patient outcomes.

Methods: Nurses engaged in research and creation of standards of care for the post-operative neurosurgical patient population. The standards were educated to the new group of nurses that would be caring for the neurosurgical post-operative patient population.

Evaluation: Weekly audits were completed to monitor adherence to protocols. The Plan, Do, Check, Act Cycle was used to continue to evaluate effectiveness of education. New education and interventions were created when inconsistencies were found (such as adding neurosurgery metrics to High Reliability Organization Board, following up with nurses to identify barriers, visual reminders, etc.). The Michigan Spine Surgery Improvement Collaborative (MSSIC) collects data related to post-operative complications for neurosurgical patients, such as deep vein thrombosis, urinary retention, and urinary tract infections. This data was pulled from MSSIC and compared pre and post intervention.

Results: Adherence to early IUC removal by post-op day 1 and early ambulation within 8 hours of surgical case close increased. The increase in adherence to these protocols led to a decrease in the post-operative complications of deep vein thrombosis, urinary tract infection, and urinary retention.

Implications: Implementation of a post-operative neurosurgical standard of care protocol showed a decrease in post-operative complications. This can potentially be applied to other neurosurgical units, as well as other areas caring for post-operative patients other than neurosurgical to decrease complications post-operatively.

CNS Improving Outcomes
Quality Initiatives
Interprofessional Collaboration

Purpose:

The purpose of this quality improvement project is to develop an innovative solution to reduce device related nares pressure injuries (NAPIs) in the adult inpatient populations.  

Participants and Settings:

Participants include adult inpatients and nursing staff that provided direct patient care in a Midwest Magnet designated 664 bed academic medical center.

Design:

Systematic quality improvement methodologies yield a creative method for preventing nares pressure injuries beyond the recommended securement device. (18 words)

Methods:

A team of clinicians identified the “T” – shaped hydrocolloid protective barrier as a key driver in reducing device related pressure injuries related to a nasogastric or small bore feeding tube. In conjunction with patient assessments and a securement device, the nurse driven NAPI bundle was implemented to reduced pressure on the nares. 

Results:

This quality improvement project yielded positive and sustainable results. In FY15, the house wide baseline NAPI incidence rate was 5.6%. In FY16, the Surgical Intensive Care Unit pilot confirmed design effectiveness that yielded a 70% NAPI reduction. In June FY16, the pilot expanded to all adult inpatient units leading to further decline of NAPIs to 3.5%. In FY17, results were further reduced and sustained as the organization exceeded it targets, with incidence rates of 1.6%. 

Conclusion:

Success was achieved utilizing the nurse driven NAPI bundle to enhance patient safety. Data   reflects adult inpatients with a nasogastric or small bore feeding tube benefit from the innovative “T”-shaped hydrocolloid protective barrier, securement device and additional NAPI bundle components. Significant sustainable results led to a reduction in nares acquired pressure injuries in adult inpatients. 

CNS Improving Outcomes
Quality Initiatives

Obstetric hemorrhage is one of the mostly deadly and preventable conditions related to pregnancy and childbirth. Between 54-93% of hemorrhage deaths may be preventable and provider management accounts for 90% of the preventable mortality. Prompt recognition and treatment are key in the survival of both mother and baby.

The current standards for hemorrhage are a blood loss of over 500ml for a vaginal delivery or 1000ml for a cesarean section. Estimated blood loss (EBL) is inaccurate and underestimated. New standards include quantification of blood loss (QBL), which measures blood loss via calibrated collection devices and scales.

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives
Capture Value of the CNS

Title Questioning the Culture: The Implementation of Case Reviews to Reduce Hospital Acquired Infections

 

Significance & Background

 

Hospital acquired Clostridioides difficile (C.diff) infections have had nearly a three-fold increase since 2000, necessitating the implementation of evidence-based practice. Catheter-associated urinary tract infections (CAUTI) are a leading cause of hospital acquired infections (HAI) in adults. The average cost of a hospital acquired CAUTI is $13,793, and C.diff infection is $17,260. At a midwestern academic hospital, an increase in hospital acquired C.diff and CAUTI occurred and were attributed to inappropriate testing. The advanced practice registered nurse (APRN) is uniquely qualified to assist in reducing HAIs because of his or her contribution to system-level change and focus on improved patient outcomes. 

 

Evaluation Methods

After a thorough investigation it was determined a potential cause of these HAIs may have been due to inappropriate testing. The Clinical Nurse Specialist (CNS) team, in collaboration with Infectious Disease and Infection Prevention, developed case review forms with specific evidence-based criteria to ensure cultural stewardship. The case review forms required a comprehensive chart review that warranted the signature of a unit leadership member, in order for the laboratory to commence culturing. A specimen without a case review form was rejected by the laboratory department; this process served as an independent redundancy.

 

Outcomes 

In quarter one of 2019 the CAUTI rate for the organization was 0.83 (per 1,000 patient days), in quarter two the rate was 0.92, in quarter three 1.85, then a decline in quarter four to 0.46, then to a low of 0 in 2020 quarter one. In quarter one of 2019 the C. diff infection rate for the organization was 3.26 (per 10,000 patient days). The rates showed a decrease and stabilization in quarter two to 0.52, in quarter three to 0.52, and quarter four to 0.53, and 0.55 in quarter one of 2020.

 

Implications

This evidence-based practice process will mitigate unnecessary antibiotic administration therefore reducing antibiotic resistance, and lead to improved overall patient outcomes. The educational preparation of an APRN affords them the ability to critically appraise evidence thus being able to implement evidence-based practice. Addressing cultural stewardship is paramount in mitigating inappropriate antibiotic administration attributing to antibiotic resistance, increased length of stay and costs. Decreasing HAIs will lead to a cost reduction for the hospital which is key to financial vitality. 

CNS Improving Outcomes
Quality Initiatives
Capture Value of the CNS

Title:  The Drive to Sustain Zero: How Case Reviews Helped Sustain CLABSI  Rates

 

Significance & Background: Central line-associated bloodstream infections (CLABSI) are the eighth leading cause of death in the United States (US), accounting for 250,000 bloodstream infections annually, and have a 12-25 percent mortality rate. Of all the healthcare-associated infections, CLABSIs are associated with a high-cost burden, accounting for approximately $46,000 per case. In the US, the CLABSI rate in Intensive Care Units (ICUs) is estimated to be 0.8 per 1000 central line days. Patients in ICUs are at an increased risk for CLABSI because 48 percent of ICU patients have indwelling central venous catheters.

 

Evaluation Methods: After a thorough investigation it was determined a potential cause of the CLABSIs may have been due to inappropriate testing. The Clinical Nurse Specialist (CNS) team, in collaboration with Infectious Disease and Infection Prevention, developed a case review form with specific evidence-based criteria to ensure cultural stewardship. The case review form required a comprehensive chart review and leadership approval. To sustain compliance with the form, the CNS team developed a “Question the Culture” initiative that included flyers, huddles, and in-person education sessions. 

 

Outcomes: Before case review implementation, in quarter two of 2019, the CLABSI rate for the organization was 0.1 per 1,000 patient days. After implementation of case reviews in quarter four of 2019 the CLABSI rate was 0, in quarter one of 2020 it was 0.05, quarter two was 0.1, and quarter three declined to a rate of 0. With the implementation of the case reviews we were able to keep the rate stable or show a reduction through some quarters. 

 

Implications: Obtaining a CLABSI rate of zero has been challenging, but cultural stewardship has afforded us the insight to optimize patient outcomes.  This comprehensive undertaking became part of the “culture of the organization” from an interdisciplinary standpoint as several disciplines were involved in the development and education for this process. This initiative, if further adopted within other health care systems, has the potential to reduce unnecessary antibiotic exposure, mortality, and cost burden.  

CNS Improving Outcomes

Cystic Fibrosis is a life-limiting disorder that affects many organ systems, but primarily the lungs.  In Cystic Fibrosis, the loss of chloride transport causes airway mucus obstruction, leading to chronic airway infection and inflammation.  Airway Clearance Therapy is essential to the care and treatment of patients with Cystic Fibrosis.  The aim of this presentation is to demonstrate how the use of a Multidisciplinary Care Pathway can improve care delivery and Airway Clearance Therapy.  At a large academic medical center, Airway Clearance Therapy increased by 50% over a three quarter period following the implementation of a care pathway. 

CNS as Researcher
CNS as Project Manager
Capture Value of the CNS
Interprofessional Collaboration

Background

The U.S. military prides itself in delivering optimal care to its members often in unpredictable, unforeseeable, and austere conditions. In these types of healthcare environments, moral and ethical situations are likely to occur. Little research has been completed documenting moral distress and/or moral injury in military healthcare providers. A PhD-prepared Clinical Nurse Specialist is optimally trained to address this formidable but critical topic for the best patient, provider and system outcomes. A scientific approach, while incorporating the wholeness and the intricacies of patient care in a military health system, was necessary to produce reliable evidenced-based practice measures for trusted care delivery to our military members.

Methods

The purpose of this project was to examine the topic of moral distress and moral injury in military critical care nurses across all service branches. This project was implemented in three phases: 1) background, 2) tool building workshop, and 3) tool testing. In the background phase of these efforts, the concepts of moral distress in healthcare providers and moral injury in the warfighter were examined by an expert panel according to the Joanna Briggs Institute scoping review methodology. Phase two of the study adapted the existing Moral Distress for Healthcare Professionals (MMD-HP) tool to measure moral distress in military critical care nurses while incorporating the concepts of moral injury as warfighters. In the final phase, testing of the tool is currently being conducted in critical care nurses across all military branches.

Outcomes

            A scoping review of the two topics was performed resulting a more explicit understanding of the similarities and differences between the concepts. Next, a three day workshop was conducted to bring thirteen military and civilian representatives assembled to adapt the existing civilian tool to a military critical care nurse application. This tool refinement included integration of moral distress, moral injury, and military and critical care relevant concepts through application of evidenced-based findings, subject matter expert recommendations and tests of validity. A tool testing plan was developed on the last day of the workshop. The workshop resulted in the MMD-HP-M (military version) and is in the data collection phase with dissemination to all critical care nurses, across all military branches. These results will help to validate the psychometric outcomes of the revised tool, as well as, establish reliability of the original questions to this healthcare population.

Implications

Military members practicing in these healthcare environments are simultaneously healthcare providers and warfighters, which may pose situations where both moral distress and moral injury are applicable. These efforts will help to add to our foundational knowledge of the concepts and produce evidenced-based interventions to lessen the long-term consequences of these phenomena. A PhD-trained CNS is one of few advanced practice clinicians trained to incorporate the needs of the provider, patient and families, uniqueness of the system, and complexities of healthcare delivery to optimize outcomes. Direct care expertise, advanced knowledge of the topic and an understanding of the unique military healthcare system was necessary to address moral distress and moral injury to reduce suffering and optimize healthcare delivery.

CNS as Researcher
Interprofessional Collaboration

 

Assessing Nutrition Status in an Outpatient Wound Center: A Feasibility Study

Background and Significance

Adequate nutrition is necessary for wound healing, yet there is little consensus identifying a particular tool to measure the degree of malnutrition in patients with chronic wounds, however, the Patient Generated Subjective Global Assessment (PG-SGA) is well-respected by dietitians. Early identification of patients at risk for malnutrition and other barriers to healing could minimize morbidity and trigger the implementation of interventions to improve outcomes in this population.

Evaluation Methods

The PG-SGA, Food Security, and demographic survey was used. The PG-SGA has two parts: a self-report nutrition status survey instrument and a structured clinical assessment performed by a Registered Dietitian that generates a risk score. A convenience sample of patients seeking care for their chronic wounds in an outpatient wound clinic in Northeastern Ohio were recruited for participation. Since the aim of the study was feasibility, a sample of 15 patients was used.

Outcomes

Of the 6 benchmarks related to process and resources established in the research protocol, only time taken for the participant to complete the patient potion of the survey was not achieved. The five remaining benchmarks attained results well within the criteria.

Two participants reported 7 or more symptoms that prevented them from eating. Based upon interpretation of total PG-SGA scores, all participants would require patient education related to nutrition and symptom management. Twelve participants (80%) would require intervention by a dietician, and two (13%) show a critical need for symptom management and nutrition intervention.

Implications

In consideration of the feasibility endpoint criteria, it is feasible to conduct a larger study if resources in terms of staff time were approved. However, the degree of ambiguity and subjectivity in the patient-generated portion of the tool may skew the validity of the results in this population. Further study would require re-examination of the tool.

CNS Improving Outcomes
CNS as Researcher
CNS as Project Manager
Capture Value of the CNS

Significance and Background: Healthcare-associated infections result in over $20,000 in non-reimbursable healthcare costs per infection. Keyboards harbor bacteria associated with these infections and require frequent cleaning and meticulous hand hygiene to prevent the spread of bacteria. However, this behavior is inconsistent with regards to nursing staff and keyboard usage. Ultraviolet light decreases bacteria on surfaces. Automating the cleaning of keyboards with ultraviolet light can reduce cross contamination between these surfaces and patients. The purpose of this evidence-based practice project was to evaluate the effectiveness of ultraviolet disinfection of hospital keyboards compared to current practice within medical surgical inpatient environments. Evaluation Methods: To allow for paired sampling, both desktop computer and workstations on wheels keyboards were labeled by unit and number. Using standard microbiology techniques, the keyboards were sampled and the swab was streaked onto a 5% blood agar plate. After 24 hours of incubation, each plate was manually counted and the total number of bacterial colonies annotated. Additionally, a clinical microbiologist visually reviewed each plate and completed identification of bacteria suspected of being associated with healthcare-associated infections. After baseline sampling was completed, ultraviolet devices were installed on 31 keyboards. Post-intervention swabbing, counting and identification mirrored the baseline methods. Outcomes: Baseline sampling was conducted on 35 keyboards. A two-tailed paired t-test was conducted on the intervention and control keyboards. There was a significant difference in the colony forming unit counts from baseline (M=74.81, SD=57.96) and after ultraviolet light installation (M=28.25, SD=30.40) conditions; t(15)=2.81, p = 0.013.  Initial bacteria identification found Staphylococcus aureus on 40% of the keyboards (14/35) and Micrococcus on 60% of the keyboards (21/35).  This decreased post intervention with Staphylococcus aureus identified on 6% of the keyboards (2/32) and Micrococcus on 6% (2/32) of the keyboards. We found no difference in our control results. Implications: This project highlights the fact that computer keyboards are a high touch surface that can harbor bacteria consistently associated with healthcare-associated infections. It also builds on prior research demonstrating the effectiveness of ultraviolet devices on keyboards that are difficult and burdensome to clean with traditional chemicals and wipes. Ultraviolet devices for keyboards are a relatively low cost investment. The prevention of one infection with these devices would offset the cost of more than 60 of these devices. Beyond the financial benefits, technology like this has the potential to improve patient outcomes and reduce the occurrence of healthcare-associated infection.

 

 

Other

There is documentation that supports academic to practice gap. Review of literature supports the need to form partnerships and provide opportunities to leverage opportunities to increase the effectiveness of new nurses in the organization. This session will share our organizations journey to meet the needs within our community. Topics covered will include steps taken to create a partnership, conceptual to reality for development of the content for the student workshop, and the faculty workshop. Discussion will include lessons learned, future opportunities. Outcome metrics proved will support this program through percentage of hiring of those who participate in the program and retention rates.

CNS as Researcher

Significance & Background:

A culture of inquiry encourages nurses to review existing research and integrate evidence-based outcomes into practice to improve patient care. When evidence is limited, nursing research can be conducted.  Barriers like lack of time, knowledge, resources, and support deter bedside nurses from conducting research. The CNS can play a vital role in laying the framework for successful implementation of research by the beside nurse. The purpose of this presentation is to discuss two CNS roles in supporting nursing staff in conducting research through the three spheres of impact.

Evaluation Methods:

Our Blood and Marrow Transplant (BMT) CNS partnered with the Nursing Research CNS, to support study teams consisting of staff nurses and a biostatistician to address research queries. Together, both CNSs support the development of nursing research protocols and mentoring of staff throughout the process. The Research CNS plays a key role in the regulatory approval processes while the department-based CNS is vital to the data collection procedures. This collaborative partnership is also evident in the mentoring of nurses for dissemination of findings through internal/external presentations and manuscript preparation and submission.

Outcomes:

To date, four nursing research studies have been conducted on the BMT unit.  Twelve BMT nurses have participated in nursing research as a study team member or served as principal investigator.  Three studies have been completed, presented among six conferences, and published. The study outcomes have resulted in a change of practice and have been implemented house wide. The fourth study is in progress.  

Implications:

By partnering within their respective roles, the CNSs have increased the comfort level of staff with the nursing research process by decreasing barriers.  Since the success of the initial study, the CNSs built momentum by enriching a spirit of inquiry that continues to date, making research bedside-nurse friendly. The CNS as a researcher impacts the three spheres of practice by improving patient care, developing nursing staff and supporting organizational values and initiatives.

CNS as Researcher

Significance/Background: Delirium increases the risk for long-term cognitive decline and mortality. This exploratory study evaluated the use of a limited lead EEG device for objective identification of delirium with the aim of early initiation of treatment. Specifically, are there reductions in alpha wave (awake wave) percentage with significant decreases in power, increases in theta wave (twilight sleep) and delta wave (deep sleep) percentage and power, and delta and theta wave intrusion that lead to a higher theta/alpha ratio and delta/alpha ratio in patients who are CAM-ICU positive, indicating delirium? 

Evaluation Methods: This prospective exploratory pilot study used a correlational design and mixed models to explore the relationships between hand-held portable EEG data and delirium status. To fully explore the data, several methods were utilized to evaluate differences in ratios between delirium positive and delirium negative subjects. Initial observations were treated as independent observations and all observations were explored using mixed models.

Outcomes: While this study did not find statistically significant differences there was a trend to higher ratios in subjects with delirium compared to those who did not have delirium when comparing only first observations and in mixed models controlling for random effects. In a sample size of 17 it is likely the sample sizes were too small to detect statistically significant differences. The fact that ratios were higher and were approaching significance is impressive and warrants further investigation.

Implications : Limited lead EEG may be useful in predicting adverse outcomes and risk for delirium in older critically ill patients. Therefore, further investigation of limited lead EEG for delirium detection is warranted. Until these devices can be validated, nurses should continue to use validated bedside clinical tools with frequent reeducation and competency validation to minimize practice drift.

Other

• Title: Guidelines for the Management of Severe TBI
• Significance & Background: Aggressive, protocolized care with evidence-based guidelines can improve outcomes in severe TBI patients (Cnossen et al., 2018). This project establishes guidelines for the care of the adult, severe TBI patient. These guidelines provide stepwise actions for the management of increased intracranial pressure, evidence-based goals for care, and interventions to maximize recovery

• Evaluation Methods: Ventilator days, ICU length of stay (LOS), hospital LOS, Glasgow Outcome Scale-Extended scores at hospital discharge, six months and 12-months post-discharge will be used to evaluate efficacy. Decreased ICU length of stay and hospital length of stay may be used to measure cost savings to the hospital after implementation.
• Outcomes:Ideal outcomes would be decreased ventilator days, decreased ICU days, and hospital LOS as well as improved GOS-E scores at six- and 12-months post-discharge.

• Implications: Aggressive TBI care using protocolized guidelines will not only streamline patient care, but also improve outcomes.

CNS Improving Outcomes
CNS as Researcher
Quality Initiatives

The recognition that new graduate RNs enter the work force with minimal academic preparation in the assessment and treatment of pressure injuries prompted a project to improve knowledge and practice for this cohort of RNs within their first year of practice. A one day clinical shadowing experience; rounding with wound and ostomy nurses was scheduled following a comprehensive review of pressure injuries via a learning management module. A twenty five question pre-test regarding pressure injury knowledge, prevention, and management was administered prior to the shadowing experience. The outcome of the shadowing experience was to see an improvement of knowledge on the same post- test after having had the opportunity to translate knowledge into practice at the bedside. In the future, improved knowledge correlated with hands on visualization and practice will decrease pressure injuries in patients cared for by new RNs.

Other

The role of the CNS is constantly evolving and advancing along with all aspects of healthcare and APRN practice. Unfortunately, in many states, CNS practice is ambiguous in comparison to the other APRN roles. While this issue often relates to misunderstanding of the CNS role, lack of knowledge of CNS educational requirements, and uncertainty about the CNS skill set, innovations in CNS education can help level the playing field among other APRN counterparts. The focus of this presentation is to discuss various advances in CNS education related to specialty course development, advanced practice skills simulation experiences, and post-graduate preparation including certification and employment. The development of a course for students wishing to change patient population in order to become a CNS will increase the number of practicing CNSs. The combination didactic and clinical diagnostic management course prepares students who are eligible for prescriptive authority, while the addition of required specialty clinical rotations gives students a boarder perspective of the CNS role. The simulated Clinical Skills Intensive affords students the opportunity to learn multiple advanced practice skills that are useful in the healthcare setting in alignment with other APRN roles. Post-graduate preparation includes the development of Certification Exam Prep Modules that are interactive and integrated throughout the CNS curriculum in addition to construction of a professional portfolio. This session will discuss each of the aforementioned topics in great detail so that other CNS educators may utilize these tools to help improve CNS education nationwide.

CNS Improving Outcomes
CNS as Researcher
Quality Initiatives

 

Background:  In recent literature, progressive early mobility has been a focus for the Intensive Care Units (ICUs); however minimal literature exists for the medical population.  Decreased mobility and prolonged bedrest have been associated with increased length of stay, increase risk for falls and skin breakdown, as well as increased need for extended-care facility admission.  Mobility status is not commonly measured by nursing, declines in mobility are often not recognized, and Physical Therapists have been the primary drivers for patient mobility.

Aims:  In hospitalized medical patients, does a nurse driven mobility program utilizing the AM-PAC 6 Clicks assessment reduce length of stay and decrease skilled nursing facility admissions?

Method: Using a Quasi-experimental design and convenience sample, a nurse driven Mobility Program was implemented on two medical units within an acute care hospital system.  The target population were patients admitted to the Renal Medical-Surgical unit at Community Hospital East and the Medical unit at Community Hospital South.   All staff (unlicensed and licensed) received education on the mobility program including mobility equipment and the AM-PAC 6 Clicks assessment.  The AM-PAC 6 Clicks assessment was completed upon admission to the unit, daily, and upon discharge.  Based on the 6 Clicks score, the patient’s mobility program was developed within 4 phases (ranging from Range of Motion to ambulation in halls).  Staff then implemented the associated mobility phase.  When a patient met their mobility goal, the next phase of mobility was attempted.

Result: 

There was a statistically significant reduction in length of stay for patients who had increased frequency of mobility (n=200; rho= 0.3, p=0.0005).  Nurses were able to accurately score AM-PAC 6 Clicks when compared to the score conducted by a physical therapist (n=65; Pearson correlation coefficient is 0.85, P-value < 0.05). 

Conclusion: Nurses can accurately utilize the AM-PAC 6 Clicks mobility assessment tool for medical patients within the hospital, as well as effectively implement a mobility program utilizing this score.  Using the 4 phase mobility model, nursing can progress a patient’s mobility across the continuum and allow for more appropriate physical therapy intervention.  Providing an accurate tool to assess a patient’s mobility and model of progression can impact length of stay, quality indicators, and provide a communication tool with Physical Therapy fostering a more multidisciplinary approach to mobility. 

Limitations: We compared the length of stay for the month before the study began, compared with the duration of the intervention.  The intervention occurred during peak flu season, which may be a reason that we did not see the length of stay outcomes we had been anticipating.  We were also limited in the data collection nearing the end of the study, as the COVID-19 pandemic was spreading across the country.  This limited the number of patients data we could collect in our implementation group.

 

 

 

CNS as Researcher

Sleep is essential for maintenance of good health and well-being; however, for nurses who work the night shift, getting the recommended eight hours of sleep can be difficult. As there are many deleterious effects of sleep fatigue, it is crucial for nurses entering the profession to establish positive sleep hygiene habits. A prospective, experimental, pre-survey and post-survey design was used to examine the effect of an educational sleep program on sleep quality, quality of life, and fatigue severity for new graduate night nurses. In the pre-program survey, 184 nurses participated (experimental [n=84], control [n=102]). There were significant differences between the control and experimental groups for the aggregate totals of the Pittsburgh Sleep Quality Index (PSQI) and the Quality of Life Index (QOLI) as well as some of the subscales but not the General Sleep Disturbances Scale (GSDS) or the Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F). After the program 41 nurses completed the survey (experimental group [n=20], control group [n=21]). For the PSQI sleep duration and disturbances subscales, although there was not a significant main effect for within-group or for between-group, there was a marginally significant interaction of within- and between-group. For the PSQI sleep dysfunction subscale, the within-group main effect was significant, the between-group main effect was marginally significant, and the interaction was significant. For the VAS-F fatigue subscale, the within-group main effect was significant, the between-group main effect was not significant, and the interaction was significant. Other main effects were found. This shows initial evidence that the sleep educational program may have some effect on quality of sleep and fatigue but not quality of life.

CNS as Researcher

The clinical nurse specialist is in a unique position to identify nursing and patient care issues that will lead to improved practice and enhanced patient outcomes. However, they are often stopped from fully investigating these issues because they lack the information necessary to evaluate and/or create valid and rigorous instruments and scales needed to capture the research data their studies require. Few, if any graduate nursing programs provide sufficient coursework related to instrument and scale development and testing. Understanding how to evaluate existing instruments and scales and learning how to develop new instruments and scales that better meet the needs of nursing researchers is an important role for the clinical nurse specialist.  This short course will provide hands-on experiences in instrument and scale development. In addition, at the end of the presentation all attendees will receive a link to a toolbox specific to this topic created and maintained by this presenter.