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Vol. 23, No. 11, NOVEMBER 2006


Implementation of AACN Practice Alerts

By Christine Schulman, RN, MS, CNS, CCRN
and Jan Powers, RN, MSN, CCRN, CCNS, CNRN
2005-06 Research Work Group

The purpose of the AACN Practice Alerts (PA) is twofold: to provide bedside clinicians with a review of the current literature regarding important practice concerns and to identify how current evidence can be integrated into individual practice and hospital policy. Successful implementation of any practice change, however, requires knowing how to navigate the key steps in the change process. These steps include identifying the need, gathering a team, developing plans for implementation and education, and evaluating the impact of the change. This article discusses each of the steps in greater detail to help the clinician influence simple practice changes as well as those that are politically sensitive.

Identifying the Need
Identify the need to change a specific clinical practice in your unit. After identification of the need to alter practice, approach colleagues and ask for their input. The goal is to make sure that there is agreement with your assessment and to recruit assistance. Usually, the next step is to complete a literature review to learn the full scope of the issue and compare it to your unit’s baseline practice. In the case of published AACN PAs, this has already been done so you are able to quickly move on to the next step. Identify and approach stakeholders for their input to help clarify who will provide administrative support and discover potential roadblocks to the project.

Gathering the Team
Appropriate team composition is critical to any project’s success. In addition to the staff members who support the project, naysayers should be invited. Naysayers give valuable insight about the potential challenges the work group will face and help develop a plan that will be acceptable to as many people as possible. The presence of both expert and novice clinicians assures that opposing viewpoints on any given clinical issue are represented. The clinical nurse specialist and specialty educator for the unit are instrumental in interpreting the literature and navigating the process through the appropriate institutional channels. Depending on the project, physicians and ancillary personnel such as respiratory therapists or nutritionists may need to be included to ensure acceptance by the other professional groups affected by the change. Finally, the person with administrative authority over the project (i.e., nurse manager or division director) should be invited to participate; although the nurse manager or director may not be able to attend meetings, he/she must be informed of progress, potential costs, challenges encountered by the group and timelines for implementation.

The team is responsible for creating a seamless implementation plan that is easy for staff members to accept and use. At the first meeting, discuss why it is important for the unit to make the practice change (i.e., it improves patient safety or follows a new national standard). Identify goals, timelines and meeting schedules. Assess the level of effort required; some projects may be implemented in one or two meetings and not require intensive coordination. Others, however, will require deliberate and well-organized planning with much discussion over the course of several months. Appoint a project champion who will make sure people know what their assignments are and follow up with them to ensure that work is completed within the expected time frames.

Developing a Plan for Implementation and Education
Break down the entire project into smaller, more manageable components. Establish when various phases of the project need to be completed and make sure everyone completes his or her assigned tasks. Identify what financial resources may be required and speak with the administrative liaison about how to allocate necessary funds. Determine where the final policies regarding the practice change will be kept and who will need to give final approval for implementation. Finally, discuss how to get buy-in from nursing staff and others affected by the change. Simple strategies to do this include:
• Helping staff see the need for the practice change by providing information and education
• Developing an implementation plan that does not require extra work from the staff
• Using staff champions to “talk up” the practice change
• Providing opportunities for uninvolved staff to give their input about the project before it is a “done deal”
• Recognizing staff members who use the new practice with thank you cards, coffee cards, movie tickets or registration assistance to attend local conferences

Education and Implementation
Education during implementation is imperative for staff so they will understand why there is going to be a change in practice and the importance of implementing the change to improve patient outcomes. The education plan should provide information to the staff using a variety of methods. The methods used for education will depend on the resources available at your institution. The standard staff inservice education is often ineffective, because it is typically difficult to leave the unit due to busy patient loads. Identify creative ways to get this education to bedside care providers. Here are a few ideas for creative strategies to communicate and educate staff members: announcements at journal clubs, presentations at staff meetings, e-mail communication, posters/flyers, computer education modules, word of mouth (assigned peer-to-peer communication) or unit newsletters.

Keeping staff informed throughout the development phase of the proposed change project will make acceptance and final education easier. Such information includes which patients will be affected by the changes, how to implement the changes, and when they will occur. Final educational activities typically begin immediately prior to the official start date of the new practice; staff are more likely to remember new information if presented just prior to the change. At the time change is implemented, assure that unit experts or resources are available before, during and after implementation to answer questions as they arise.

Evaluation
Evaluation of the change should be done in at least two, and possibly more, phases of the project using surveys or practice audits to assess the effect on practice and/or patient outcomes. An assessment of baseline practice and patient outcomes should be done before implementation so that the effect can be assessed after implementation. Another evaluation should be done immediately after implementation to assess effect and potential problems with the change. Additional evaluations should also be done at predetermined future dates to assess for sustained effect and the possible need for revisions and updates or additional education of staff.

To Implement Practice Alerts
1. Identify the need
2. Select the relevant practice alert
3. Gather the team
4. Develop a plan for implementation and education
5. Evaluate the process
6. Recognize success

To Successfully Implement a Practice Change
1. Select an issue that has direct relevance to your unit’s practice.
2. Use national healthcare initiatives and professional organization care standards to help establish the need to change current practice.
3. Use resources already available that provide key information and give directions about what you need to do (i.e., AACN Practice Alerts).
4. Gather a multidisciplinary team to ensure all perspectives regarding the practice issue are well represented.
5. Select a team leader who will coordinate meetings, establish assignments and hold group members accountable for their work within expected time frames.
6. Show appreciation to those involved with the work group and to the staff who integrate the change into their practice.
7. Educate and re-educate the staff at frequent intervals until the practice change becomes routine.
8. Evaluate the effect of the practice change on clinical outcomes, financial outcomes and nurse satisfaction. Make revisions as necessary.

Final Thoughts
Remember to provide immediate feedback to colleagues about how the new practice is working. Always acknowledge and thank those involved in the process for their participation and support of the process. Last, consider lessons learned during this project as you consider bringing about the next exciting change for your unit and your patients.

What Are Rapid Response Teams (RRTs)?


National data regarding survival to discharge from an in-hospital cardiac arrest is approximately 1 in 3 patients.1 With this realization, hospitals are seeking strategies to decrease in-hospital deaths that may be preventable. Studies have indicated that, prior to a cardiopulmonary arrest, patients demonstrate serious clinical signs of deterioration.2,3 Hospitals have considered early evaluation of at-risk patients as one approach to improve patient care and overall morbidity and mortality. The concept of establishing an emergency response team was pioneered in Australia and the United Kingdom. The aim is to proactively evaluate patients to prevent a wide range of emergencies with the goal of preventing cardiopulmonary arrest.

Several different names are given to these teams in professional literature: Medical Emergency Team (MET), Rapid Response Team (RRT), Medical Emergency Response Improvement Team (MERIT), Multidisciplinary Rapid Response Team, Intensive Care Rapid Response Team and Medical Crisis Team. Whatever the name, the primary objectives of these teams are to reduce patient mortality and morbidity through timely identification, intervention and treatment of at-risk patients before they require resuscitation. Does the use of in-hospital emergency response teams decrease in-patient mortality or decrease the number of cardiopulmonary arrests? A prospective before-and-after trial of a medical emergency team determined the incidence of in-hospital cardiac arrest and death following cardiac arrest. The study concluded that “the incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing an intensive care-based emergency team.

Some studies concluded that there were fewer unanticipated intensive care admissions.4,5 Three studies concluded that clinically unstable inpatient early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital.4,6,7 Some studies were unable to conclude whether the MET alters morbidity or mortality for hospital inpatients.8,9 One study of a medical emergency team one year after implementation demonstrated a reduction in cardiac arrest rate and overall mortality but this was not statistically significant.10 Most studies concluded that further research is needed to determine the impact of these teams on overall morbidity and mortality. Overall, emergency teams have had a positive impact on quality of care.

The Institute of Healthcare Improvement’s 100,000 Lives Campaign has a Web page designated to establishing a rapid response team, which includes a “Getting Started Kit: Rapid Response Teams How-to Guide” available at the following Web address: http://www.ihi.org/IHI/Topics/CriticalCare /IntensiveCare/Changes/EstablishaRapidResponseTeam.htm.
To learn more about Rapid Response Teams, AACN offers a CE course, “Critical Care is a Process, Not a Location: Rapid Response Teams,” available at http://www.aacn.org /AACN/conteduc.nsf/vwdoc/GlobalCEWELCOME?opendocument. On this Web page, click on AACN Members-Free CE, which will show a current list of free CE courses provided to AACN members as an online benefit.

References
1. Ebell MH, Becker LA, Barry HC, Hagen M. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med. 1998 Dec; 13(12):805-16.
2. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994. 22(2):189-91.
3. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990 Dec; 98(6):1388-92.
4. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003 Sep 15; 179(6):283-7.
5. Bristow PJ, Hillamn KM, Chey T, et al. Rates of in-hospital arrest, deaths and intensive care admissions: the effect of a medical emergency team. MJA. 2000. 173:236-240.
6. Buist MD, Moore DE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrest in hospital: preliminary study. BMJ. 2002 16; 324(7334)387-90.
7. DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, et al. Qual Saf Health Care. 2004 Aug: 13(4):251-4.
8. Daly FF, Sidney KL, Fatovich DM. The Medical Emergency Team (MET): a model of the district general hospital. Aust N Z J Med. 1998. 28(6): 795-8.
9. Salamonson Y, Dairyawasm A, Van Heere B, O’Connor C. The evolutionary process of Medical Emergency Team (MET) implementation: reduction in unanticipated ICU transfers. Resuscitation. 2001 May; 49(2):135-41.
10. Kenward G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team one year after implementation. Resuscitation. 2004. Jun; 61(3):257-63.

Grants

Applications are due Jan. 1 for the following grants:
Clinical Inquiry Grant—Annually funds 10 awards of up to $500 each for projects that directly benefit patients and their families.
End-of-Life/Palliative Care Grant—Annually funds two awards of up to $500 each for projects that may include bereavement, communication issues, caregiver needs, symptom management, advance directives or life-support withdrawal. Evidence-Based Clinical Practice Grant—Annually funds six awards of up to $1,000 each for projects that can include research utilization, quality improvement or outcome evaluation. AACN Mentorship Grant—Funds one $10,000 award for a project providing research support to a novice researcher.
AACN Critical Care Grant—Annually funds one $15,000 award for projects focused on one or more of AACN’s research priorities.
To find out about AACN’s research priorities and grant opportunities, visit www.aacn.org . Research > Grants or e-mail research@aacn.org.

Dec. 1 Is Deadline to Submit Nominations for Distinguished Research Lecturer Award


The deadline for 2008 Distinguished Research Lecturer Award nominations is less than a month away. The recipient will present the Distinguished Research Lecture at NTI 2008 in Chicago. The lecturer receives an honorarium of $1,000, an additional $1,000 toward NTI expenses and a crystal replica of the AACN vision icon. The award is funded by a grant from Philips Medical Systems.

To view a list of past recipients, go to www.aacn.org > Research > Awards&Recognition
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