Ambassador Best Practices: Clinical Practice Standards

Using End Tidal CO₂ monitoring for all patients with potential for altered minute volume status. The ETCO₂ value changes far quicker than SpO₂ and provides early warning of respiratory distress.

It provides an accurate airway respiratory rate. It is also used effectively when weaning patients from ventilators. I teach this application in all critical care areas in hospitals. 

1. Education in the value of the information of ETCO₂ vs. SpO₂
2. Demonstration of the ease of implementation
3. Case studies to demonstrate use of data in critical patient care  

In July 2009 I was appointed to be the hospital lead of the Clinical Application in Research and Education (CARE) project to initiate the Surviving Sepsis Campaign in our small, acute care hospital. The goal for this project is to reduce sepsis mortality by 25% and to train nurses at the bedside to be leaders in change project.

We are now screening all adult patients 18 years-old and older for sepsis.

If they are tested positive with two signs of Systemic Inflammatory Response Syndrome (SIRS) — like temperature  > 100.4, HR > 100, SBP < 90 mmHg, lactate level > 4 — we initiate Sepsis Resuscitation Bundle (to be completed within six hours of the time of presentation), which includes Early Goal Directed Therapy (EGDT), such as fluid resuscitation, blood cultures, lactate level and antibiotic therapy within one hour of diagnosis of severe sepsis or septic shock.

If all the interventions mentioned were done and the patient continues to deteriorate, we activate Sepsis Management bundle that includes tight glycemic control, Xigris, steroid therapy, etc. 

1. The idea of teamwork includes working together to achieve a common goal.
2. Regular team meetings to discuss test of change updates, off-site conferences for leadership training, quality improvement, data analysis, etc.
3. Management support empowering frontline nurses to be leaders in change project.

From November 2009 to August 2010, our compliance in sepsis screening tool and lactate levels drawn are improving significantly. Mortality rates are fairly improving and the awareness and education across the board including physician support is improving.

We developed sepsis order set for the ED, med-surg and ICU for physicians to use when patients are diagnosed with severe sepsis or septic shock.
 

I will be presenting a poster board on "Initiating Surviving Sepsis Campaign in a small acute care hospital" at the California Emergency Physician (CEP) Annual Conference in Palm Springs, California, on October 25-27, 2010.

Our best practice is accountability and our motto is "Best Practice...Is it really a choice?" Our staff has gone back to bedside reporting, and not just the report that you may have seen where one nurse hangs over the counter or table, but really going into the room and conducting a neuro exam together.

This improved best practice has helped our new staff feel more comfortable and has also helped older staff correct some old habits. We have a large number of new nurses in our unit that we felt needed to find a way to address potential errors and bad practice styles rapidly.

This best practice is working well and has improved some of our safety concerns. 

1. Compliance to improve the process
2. Accountability of staff to address an issue at the time of the report instead of discussing the bad habit later in front of everyone except the nurse who deserved the feedback
3. Manager accountability: address noncompliance 

1. Improved safety — less PSN reporting (occurrence report)
2. Improved neuro-assessment skill for new RNs (learn-by-mentor example)
3. Decreased medication errors
4. Improved staff recognition among the key stakeholders
5. Improved staff satisfaction  

Our hospital is one of 17 hospitals participating in the international PULSE trial — linking cardiac monitoring standards to bedside practice. I am the site investigator and two of our units are participating, the CCU and CVSICU.

After phase II of the experimental group our nurses have the top post-test scores in the U.S. I am leading a task force to take the guidelines to all monitored areas in our hospital. Over 90% of our CCU nurses participated in the study.  

1. Our Novice-to-Expert Cardiac Curriculum, which has been in place for over nine years, has created a culture of inquiry and knowledge. We were recognized as a 2010 NTI Best Practice for Creating a Culture of Certification.
2. Shared decision-making forum and staff engagement.
3. Cardiac leadership team support. 

As noted above, our PULSE scores and monthly quality scores showing compliance with the monitoring guidelines.

Leadership of our unit based CNS to change house-wide practice. The CCU is a three-time Beacon Award recipient. 

1. Staff engagement through standards education
2. Staff assignment of a standard because the bedside nurse knows their practice and that of their peers
3. Staff findings shared with managers to effect change 

My outcome is to have our acute and critical care units functioning at the highest standard capacity possible.

The goals by which we hope to achieve this is to maintain current, evidence-based procedures and policies. We hope to measure standard compliance within the next year.

Literature reviews are important and, although time consuming, are vital. AACN Practice Alerts have been extremely beneficial in summarizing the essence of current practice standards among widely popular topics of interest in the healthcare profession.

The subject matters posted are very timely. Having the Practice Alerts facilitates information sharing in a concise and succinct manner. Furthermore, the references are relatively current and a great place to start to review original articles as part of the full literature search.

I used the Practice Alert related to blood pressure readings as my starting point to create a new policy/procedure on how to obtain accurate readings. This was presented to the Nursing Practice Council for feedback and eventually approved. It is shared with all new graduates and is available on our Intranet for staff to reference to.  

1. Having the evidence to demonstrate.
2. Referencing AACN in itself has been influential.
3. Repeatedly sharing in various contexts, the story why this practice change is essential to patient care. 

I oversee the precepted experiences of students in their final semester of a generic nursing program, which takes me to many different area hospitals.

I have printed copies of AACN's white paper pertaining to clinical practices, as well as information about certification programs, in the notebook I carry with me as I visit facilities. When a subject comes up in daily discussion, I have easy access to this information. 

1. Know what resources exist for members online.
2. Print copies of resources pertaining to frequently discussed topics.
3. Participate in friendly conversations with colleagues — avoid being authoritarian or judgmental. It is the manner in which information is presented that determines the value to the individual.

Nurses have shared AACN's white paper information and it has been presented in staff meetings.We have updated policy and procedure manuals with this framework in mind. 

Also many nurses are preparing to take certification exams, all with the encouragement of nursing education department members and administrators.