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In the Circle: Award Recognizes
Innovative Collaboration
Editor�s note: The following excerpts are
from exemplars submitted in connection with the 2001 Innovision Award, a part of
AACN�s Circle of Excellence recognition program. This award recognizes
initiatives and programs that innovatively and collaboratively meet the needs of
families of the acute and critically ill. Up to three awards, with $2,500
earmarked to fund projects, are granted to partnerships that include an AACN
member, a healthcare provider organization and a community group. In addition,
individual recipients are given public recognition and a personalized plaque.
Clinical Ethics Center
Dearborn, Mich.
Oakwood Healthcare Systems, OHMC-D Guild
Critically ill patients must often depend upon
others to make healthcare decisions on their behalf. An advance directive can
provide guidance about a patient�s wishes for medical treatment and relieve some
of the decision-making burden. With the support of the Oakwood Hospital and
Medical Center Guild, the Oakwood Healthcare System and its Clinical Ethics
Center were able to develop several initiatives to enhance the completion of
advance directives.
Under this initiative, an innovative advance
directive education packet and program titled �My Voice�My Choice� was designed
to lead individuals through the steps of preparing a durable power of attorney
for healthcare that would be grounded in their own personal, cultural and
spiritual values and beliefs. To date, more than 3,000 educational packages have
been distributed, with translation into Arabic in progress. More than half of
those who attended the program have completed an advance directive, and program
evaluations have been positive. A 20-minute videotape was produced as a
companion piece to the education packet, enhancing its use as a
self-instructional program.
A public service announcement titled �What If�
was produced to stimulate the public thinking about medical treatment choices
and to seek more information about advance directives. The announcement,
produced in both English and Arabic, aired on local television stations and will
air on the new in-patient television network.
A project was also initiated to raise awareness
of the Michigan Home Do-Not-Resuscitate Act. Home DNR forms and educational
brochures were developed to promote awareness of the individual�s resuscitation
wishes and avoid unwanted resuscitation.
These projects support patient autonomy in
medical decision making, encourage individuals to �use their voice before they
lose their choice,� demonstrate respect for individual values and beliefs, and
promote the welfare of the individual and community by honoring the expressed
wishes of the patient.
Surgical-Trauma ICU and TBI Team 2000
Mission Viejo, Calif.
Mission Hospital Regional Medical Center
Using the latest technology and interventions,
critical care nurses provide skilled nursing care for their patients. Coupled
with this is the human side of caring. The need to provide holistic care to our
patients requires nurses to partner with others, including healthcare providers
and patients� families.
Patient outcomes for our severe, traumatic brain
injury patients have been greatly enhanced by using a new protocol. Feedback
from the families of patients regarding the transition of care from the ICU to
other settings led us to realize that an opportunity for improvement in meeting
their needs existed.
In May 2000, representatives of the ICU,
surgical unit, acute rehabilitation, physical therapy, occupational therapy,
speech therapy, respiratory therapy, social work, chaplain, pharmacy,
physicians, and four former patients and families volunteered to explore the
three care phases of hospitalization: the ICU, the transition from the ICU to
the surgical unit and rehabilitation. As goals and projects were identified,
teams were established around four areas of focus.
Team 1 developed clinical guidelines for
assessing and managing agitation, as well as an agitation scale.
Team 2 focused on physical environmental issues.
Strategies to enhance patient safety were developed by devising alternatives to
traditional restraints, using private rooms and agitation-reduction measures,
appropriate staffing ratios, and sitters. The team also worked on structuring
the environment to facilitate communication between disciplines by developing
signage to indicate patient sleep and wake cycles and stop-and-go alerts for
families and staff and by placing large, dry-erase boards in the TBI rooms in
all three units.
Team 3 focused on continuity of care by
establishing primary nurses for the TBI patients, educating nurses on special
issues related to these patients, establishing weekly patient care conferences,
allowing for liberal family visits and presence, and formalizing the transition
process of patients from the ICU to the surgical unit to acute rehabilitation.
Team 4 concentrated on support of families and
education. Activities included developing a family education book, complete with
explanations on the protocol, equipment, disease process and procedures. In
addition, the team added family lockers, sleep chairs and computers for Internet
access.
The work by staff members and patients/families
culminated in a change of culture within the institution. The team has
recognized that caring for critical TBI patients encompasses the skills of an
entire hospital and that families are valued members of that team.
Marsha Fecht, RN
Marcella L. Rogan, RN, BSN
Spinal Cord Injury Team
Indianapolis, Ind.
Clarion Health Partners-Methodist Hospital
Our 25-bed, level one, trauma neurological
critical care unit receives 80 spinal cord injury patients per year, with only
25% having deficits. After attempts to research care of the acute SCI patient
failed, an SCI team was established. Our mission statement is that we will
establish a multidisciplinary system designed to meet the needs of SCI
individuals through innovation and excellence in care, education, research and
service. Our population of concern is the SCI patient at or above C6 level.
A packet of information was developed for
distribution to the patient and family members. This packet included a letter
concerning their stay on our unit, as well as articles on both the anatomy of
the spinal cord and common questions regarding this type of injury. In addition,
a resource list of not only staff members but also local and national
organizations is available. To track our progress, an evaluation form was also
placed in the packets.
Our group has not only grown, but also been able
to share our knowledge with others. We spoke at a conference in Chicago, and
presented a poster at the national convention of the American Association of
Spinal Cord Injury Nurses. We also planned a case review for the Clarian Health
National Neurological Conference in Indianapolis.
The Power of One: Understanding the Rules
and Effecting Change
By Carol A. Puz, RN, BSN, CCRN
AACN Board Liaison
Ethics Work Group
As the healthcare paradigm shifts, we see major
changes in the way nursing care is delivered to patients. For example, the use
of unlicensed assistive personnel continues to increase as budget constraints
and the availability of licensed personnel tighten. If we are to effect change,
we must be proactive in understanding the rules and reaching beyond our current
ways.
Are you familiar with the nurse practice act in
your state? Do you know how to access this information? What are your state�s
rules and regulations governing the use of UAPs? What are your hospital�s rules
and regulations governing the scope of practice for UAPs or licensed practical
nurses?
Because many states have no rules and
regulations to govern the scope of practice for UAPs, their hospitals can freely
determine what this role will encompass. In these cases, the delegation
responsibility of RNs to ensure that the needs of patients and families are met
is elevated. There are commonly accepted rules mandating that delegated
activities involve certain �rights,� including right task, right circumstance,
right person, right communication and right feedback.1 Using the �right�
approach promotes the principle of beneficence, which is a moral obligation to
promote good and prevent or remove harm, and to promote the welfare, health and
safety of society and individuals in accordance with beliefs, values,
preferences and life goals.
AACN�s mission, vision and values are framed
within an ethic of care, which is a moral orientation that acknowledges the
interrelatedness and interdependence of individual systems and society. An ethic
of care respects individual uniqueness, personal relationships and the dynamic
nature of life. Essential to an ethic of care are compassion, collaboration,
accountability and trust. Within the context of interrelationships of
individuals and circumstances, traditional ethical principles provide a basis
for deliberation and decision making.2
Here�s an example of how you can put all this
into practice:
You have reported on duty to find an assignment
of four patients to be covered by you, the RN, an LPN and an unlicensed patient
care technician. Your first reaction is to question how you will be able to
handle this assignment and deliver safe care. You wonder how or what you can
delegate appropriately to your team member, and about your moral obligation to
your coworkers, your patients and their families.
Of the four patients, one and two are orally
intubated and on ventilators. Their secretions are moderate, and both are on
propofol. Patient three has a pulmonary artery line, and patients one, two and
four have triple lumen CVPs. Patient two is on heparin and dobutamine. Patients
three and four are on IV fluids at a keep open rate and are receiving IV
antibiotics. These two patients are alert and oriented x 3. None of the patients
have open wounds. Does this sound doable?
It may be helpful to use the Synergy Model to
define the characteristics of these patients. Patients one and two are minimally
resilient and patients three and four are moderately resilient. All four are
highly vulnerable and moderately stable. Patients one and two are not able to
participate in their care, though patients three and four have a moderate
participation level.
This means that you may be able to delegate more
of the care tasks for the two fairly stable patients to the UAP. What are your
hospital�s rules regarding LPNs and IV therapy? Can you delegate some of this
work? After the initial assessment of all the patients, you may want to delegate
the most stable ones to the LPN to complete.
Your clinical decision making around meeting the
needs of these patients is crucial. The synergy that results when patients�
needs and characteristics are matched with the nurse�s competencies will afford
the best outcomes. Remember that the American Nurses Association Code of Ethics
for Nurses states that �the nurse is responsible and accountable for individual
nursing practice and determines the appropriate delegation of tasks consistent
with the nurse�s obligation to provide optimum patient care.�3
By delegating the appropriate tasks to your team
members, you are accountable for the care that is provided. However, you are
also responding as an advocate and a moral agent to these patients. You must
trust your team members to ensure patient safety. If you believe an issue in
your area of practice involves an ethical decision related to clinical practice,
you may want to ask the following series of questions4:
� What is the ethical dimension of the issue?
� Who is involved?
� Are there benefits as well as burdens?
� Have there been similar care issues?
� What have others said about the issue?
� What do the organizational policies say about
the issue?
� What is your comfort level with the decision?
To find an ethical conclusion to the foregoing
example, you can apply these questions. For example, the ethical and legal
dimension of the issue is the fact that you are the only RN for these four
patients and may not be able to delegate some of the care to your coworkers
because it is out of their scope of practice. Who is involved? In addition to
you, the LPN and the UAP, the patients are first and foremost the center of the
issue. The benefits are in the fact that there are three of you to care for the
patients; the burden is in the fact that some of the care required is outside
the scope of practice of the LPN and the UAP. If you are unaware whether there
have been similar care issues, you should definitely seek out the answer to this
question. Ask your other coworkers if they have been faced with this issue and,
if so, how they handled the situation. Then, develop a plan that can be adapted
if this circumstance arises again. Familiarize yourself with your hospital�s
policies and procedures as they relate to practice issues. This will ease your
frustration when confronted by future occurrences. Being able to divide the work
to accommodate all of the patients� needs is crucial in answering the question
about whether you are comfortable with the situation and consider it to be safe
practice.
If you are concerned about your state�s practice
acts or want a more defined explanation of the roles of others, contact your
state board of nursing. Contact information for all state boards are listed
online at www.ncsbn.org. You can also volunteer to attend hospital committee
meetings where scopes of practice are discussed. By being the best possible
advocate for the patients� safety and well-being, you can influence the changes
necessary to create the proper skill mix for the patient acuity level.
References
1. Westfall P. Nurse attorney organization makes
UAP recommendation. Insight. 1998; 7(2).
2.http://
www.aacn.org.
3. www.nursingworld.org/ethics/chcode.htm
4. Kinsella L. Truth telling in patient care,
resolving ethical issues. Nursing. 2001;31:52-55.
Critical Care Across the Continuum:
Progressive Care Nurses Are Part of Critical Care
By LeAnn Ash, RN, BSN, CCRN
Cochair, Progressive Care Task Force
What is a progressive care or intermediate care
or step-down RN? What skills do they need to provide care for patients in their
units? What technology is needed to monitor patients on these units? What
educational tools do they need to train new nurses and continue their
educational growth? Does AACN have resources to assist these nurses in their
practice?
These are just a few of the questions probed by
members of AACN�s Progressive Care Task Force when we met in San Antonio, Texas,
in January 2002.
Prior to our face-to-face meeting in San
Antonio, we began brainstorming via a conference call in October 2001 to
identify issues relevant to progressive care nurses and specific to their
environment of care. At our meeting, we further explored these issues and ways
to address them.
Using AACN�s vision as a guide, the task force
members agreed that patients in progressive care units are critically ill, even
though they are not being cared for in the traditional ICU setting. Thus, the
task force concluded that progressive care nurses are critical care nurses who
practice beyond the walls of the ICU. We are committed to providing them the
affiliation, resources and tools that all AACN members enjoy.
Because progressive care nurses require the same
competencies, educational resources and support as other critical care nurses,
the task force believes that AACN can play a critical role in ensuring that they
are able to make their optimal contribution to the care of their patients and
families. The task force examined in depth the concept of �critical care along
the continuum� to encompass patients in progressive care as well as in ICUs.
The task force is now in the process of
assessing AACN�s vast educational resources with respect to their usefulness to
progressive care nurses and will make recommendations to the AACN Board of
Directors regarding existing resources as well as what is needed. In addition,
articles written by task force members to highlight key issues in the
progressive care arena will appear in upcoming issues of AACN News.
Members of the Progressive Care Task Force are:
� LeAnn Ash, RN, BSN, CCRN (cochair), Keller,
Texas, pediatric staff nurse
� Melissa Fitzpatrick, RN, MSN, FAAN (cochair),
Chapel Hill, N.C., editor and principal healthcare strategist
� Diane Salipante, RN, MSN, MS, CCRN, Pittsford,
N.Y., nurse practitioner, progressive care unit
� Terri �Mary� Palazzo, RN, MS, CCRN, Falls
Church, Va., director of cardiac services for a progressive care unit
� Susan Helms, RN, MSN, CCRN, Archdale, N.C.,
clinical nurse specialist
� Ray Quintero, RN, MSN, CCRN, Yorktown, Va.,
manager and educator
� Randeen Cordier, RN, MSN, Salsbury, Md.,
clinical nurse manager
� Madeleine Burke, RN, BSN, CCRN, Miami, Fla.,
nurse clinician and care coordinator
� M. Dave Hanson, RN, BSN, CCRN EMT-P (board
liaison), Dallas, Texas, nurse educator
Katie Schatz, RN, MSN, NP, clinical practice
specialist at the AACN National Office, is the staff liaison to this group.
Looking for Guidance? Apply to be a Wyeth
Nursing Fellow
Acute and critical care nurses can further
develop their professional leadership skills and be published through the AACN
Wyeth Nursing Fellows Program, now celebrating its 10th anniversary.
This nine-month fellowship, which pairs mentors
and fellows, is sponsored by Wyeth Pharmaceuticals in collaboration with AACN
and the American Journal of Nursing.
Under the program, the mentors will guide their
fellows in preparing personal plans that include completing individualized
projects, attending AACN�s National Teaching Institute and Critical Care
Exposition and developing manuscripts on a current cardiopulmonary topic for
publication in a supplement to the May 2003 issue of AJN.
The mentors and fellows will be honored at the
2003 NTI, May 17 through 22 in San Antonio, Texas. The fellows receive
complimentary NTI registration, travel and lodging. The mentors receive
complimentary NTI registration and a $500 educational grant.
Applications for the 2002-03 class of mentors
and fellows must be received by June 21, 2002. To obtain an application, call
(800) 899-2226 and request Item #2005 or AACN Fax on Demand at (800) 222-6329
and request Document #2005. Applications are also available online at
http://www.aacn.org.
For further information, call (800) 394-5995 for
AACN Clinical Practice Specialist Kathleen Schrader, RN, DNSc, CEN, at ext. 372
or Research Associate Dolores Curry at ext. 377.
Practice Resource Network
Q:
We are developing sedation guidelines for our ICU patients. Do you know of
protocols or articles that would assist us in this task?
A:
According to the �Standards and Intents for Sedation and Anesthesia Care� in the
Revisions of Anesthesia Care Standards Comprehensive Accreditation Manual for
Hospitals, the following definitions should be used when referring to sedation:
�The standards for sedation and anesthesia care
apply when patients receive, in any setting, for any purpose, by any route,
moderate or deep sedation as well as general, spinal, or other major regional
anesthesia. Definitions of four levels of sedation and anesthesia include the
following:
� Minimal sedation (anxiolysis)�a drug-induced
state during which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected.
� Moderate sedation/analgesia (conscious
sedation)�a drug-induced depression of consciousness during which patients
respond purposefully to verbal commands, either without or accompanied by light
tactile stimulation. No interventions are required to maintain a patent airway,
and spontaneous ventilation is adequate. Cardiovascular function is usually
maintained.
� Deep sedation/analgesia�a drug-induced
depression of consciousness during which patients cannot be easily aroused but
respond purposefully following repeated or painful stimulation. The ability to
independently maintain ventilatory function may be impaired. Patients may
require assistance in maintaining a patent airway, and spontaneous ventilation
may be inadequate. Cardiovascular function is usually maintained.
� Anesthesia�consists of general anesthesia and
spinal or major regional anesthesia. It does not include local anesthesia.
General anesthesia is a drug-induced loss of consciousness during which patients
are not arousable, even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Patients often require
assistance in maintaining a patent airway, and positive pressure ventilation may
be required because of depressed spontaneous ventilation or drug-induced
depression of neuromuscular function. Cardiovascular function may be impaired.�
(Visit
http://www.jcaho.org/search_form.html)
AACN Position
AACN approved the joint position statement
titled �Role of the Registered Nurse (RN) in the Management of Patients
Receiving Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical
Procedures,� which was authored by AWHONN.
IV Conscious Sedation
Intravenous conscious sedation is produced by
the administration of pharmacological agents. A patient under conscious sedation
has a depressed level of consciousness but retains the ability to independently
and continuously maintain a patent airway and respond appropriately to physical
stimulation and/or verbal command. It is within the scope of practice of a
registered nurse to manage the care of patients receiving IV conscious sedation
during therapeutic, diagnostic, or surgical procedures provided the following
criteria are met:
� Administration of IV conscious sedation
medications by non-anesthetist RNs is allowed by state law and institutional
policy, procedure, and protocol.
� A qualified anesthesia provider or attending
physician selects and orders the medications to achieve IV conscious sedation.
� Guidelines for patient monitoring, drug
administration and protocols for dealing with potential complications or
emergency situations are available and have been developed in accordance with
accepted standards of anesthesia practice.
� The RN managing the care of the patient
receiving IV conscious sedation shall have no other responsibilities that would
leave the patient unattended or compromise continuous monitoring.
� This nurse is able to:
1. Demonstrate the acquired knowledge of
anatomy, physiology, pharmacology, cardiac arrhythmia recognition and
complications related to IV conscious sedation and medications.
2. Assess total patient care requirements during
IV conscious sedation and recovery. Physiologic measurements should include, but
not be limited to, respiratory rate, oxygen saturation, blood pressure, cardiac
rate and rhythm and patient�s level of consciousness.
3. Understand the principles of oxygen delivery,
respiratory physiology, transport and uptake, and demonstrate the ability to use
oxygen delivery devices.
4. Anticipate and recognize potential
complications of IV conscious sedation in relation to the type of medication
being administered.
5. Possess the requisite knowledge and skills to
assess, diagnose and intervene in the event of complications or undesired
outcomes and to institute nursing interventions in compliance with orders
(including standing orders) or institutional protocols or guidelines.
6. Demonstrate skill in airway management
resuscitation.
7. Demonstrate knowledge of the legal
ramifications or administering IV conscious sedation and/or monitoring patients
receiving IV conscious sedation, including the RN�s responsibility and liability
in the event of an untoward reaction or life-threatening complication.
� The institution or practice setting has in
place an educational/competency validation mechanism that includes a process for
evaluating and documenting the individuals' demonstration of the knowledge,
skills and abilities related to the management of patients receiving IV
conscious sedation.
� Evaluation and documentation of competence
occurs on a periodic basis according to institutional policy.
Additional Guidelines
Following are some additional guidelines:
� Intravenous access must be continuously
maintained in the patient receiving IV conscious sedation.
� All patients receiving IV conscious sedation
will be continuously monitored throughout the procedure as well as the recovery
phase by physiologic measurements, including, but not limited to, respiratory
rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and patients�
level of consciousness.
� Supplemental oxygen will be immediately
available to all patients receiving IV conscious sedation and administered per
order (including standing orders).
� An emergency cart with a defibrillator must be
immediately accessible to every location where IV conscious sedation is
administered. Suction and a positive pressure breathing device, oxygen, and
appropriate airways must be in each room where IV conscious sedation is
administered.
� Provisions must be in place for back-up
personnel who are experts in airway management, emergency intubation, and
advanced cardiopulmonary resuscitation if complications arise.
AACN Protocol for Practice
The AACN Protocol for Practice titled �Sedation
and Neuromuscular Blockade in Patients with Acute Respiratory Failure,� which
incorporates detailed nursing practice implications and an annotated
bibliography, can be purchased by calling (800) 899-2226 (Request Item #170725)
or online at
http://www.aacn.org>
Bookstore. The price is $11 ($14 for nonmembers).
For additional information and a list of
suggested reading, visit the AACN Web site.
Grants
End-of-Life/Palliative Care Grants Are New
Two new small project grants of $500 each are
now available to fund studies related to end-of-life or palliative care outcomes
in critical care. Applications are due July 1, 2002. The application can be
downloaded from the AACN Web site at www.aacn.org > NEW! AACN End-of-Life Grant.
Eligible projects may address a range of topics,
including bereavement, communication issues, caregiver needs, symptom
management, advanced directives and life support withdrawal. The research may
focus on any age group and may include patient education programs, staff
development programs, competency-based educational programs, CQI projects,
outcomes evaluation projects or small clinical research studies. Collaborative
projects are encouraged.
July 1 is also the deadline for two other small
project grants:
Clinical Inquiry Grant
Up to $500 will be awarded for projects that
directly benefit patients or families. Interdisciplinary projects are especially
invited. The principal investigator must be currently employed in a clinical
setting and directly involved in patient care.
Medtronics Physio-Control AACN Small Projects
Grant
Funding of up to $1,500 will be awarded for
projects focusing on aspects of acute myocardial infarction, cardiac
resuscitation, sudden cardiac death, use of defibrillation, synchronized
cardioversion, noninvasive pacing or interpretive 12-lead ECG. Collaborative
projects are encouraged. This grant is funded by Medtronics Physio-Control.
The grants application book can be downloaded
from the AACN Web site at
http://www.aacn.org. or is
available from Fax on Demand at (800) 2226-329 (Document #1013).
Research and Creative Solutions Abstracts
Invited for NTI 2003
Sept. 1 is the deadline to submit research and
creative solutions abstracts for AACN�s 2003 National Teaching Institute and
Critical Care Exposition, scheduled for May 17 through 22 in San Antonio, Texas.
Abstracts must be relevant to the care of the
acute and critically ill or critical care nursing and must be noncommercial in
nature. The first author must be a nurse holding current AACN membership. Only
completed research and finished projects are eligible, and abstracts must not
have been previously published or presented nationally.
The designated presenters of accepted abstracts
receive a $75 reduction in NTI registration fees. All other expenses are the
responsibility of the presenter, who can be either the first author or a
designate of the author.
In addition, four awards will be presented for
oral research abstracts reflecting outstanding original research, replication
research or research utilization. Each of these awards provides an additional
$1,000 toward NTI expenses.
Following is information about the abstracts:
Research
Abstracts can focus on any aspect of critical
care nursing research, including reports of research studies or reports of
research utilization. Only abstracts of completed projects will be accepted.
Abstracts reporting research studies must address the purpose; background and
significance; methods; results; and conclusions.
Creative Solutions
Abstracts should focus on specific strategies
and practice innovations that are used by nurses to solve difficult, unique or
interesting problems in patient care, nursing practice, nursing management or
nursing education. The creative solution must have been implemented, with
outcomes evaluated. Abstracts must address the purpose of the project and
include a description of the creative solution, as well as evaluation and
outcomes.
To obtain abstract forms, call (800) 899-AACN
(2226) and request Item #6007, or visit the AACN Web site.
In the Circle: Award Spotlights
Multidisciplinary Team Collaboration
Editor�s note: The following are excerpts
from exemplars submitted in connection with the 2001 Multidisciplinary Team
Award, a part of AACN�s Circle of Excellence recognition program. This award
recognizes multidisciplinary teams that clearly practice key principles of
collaboration and multidisciplinary practice. Team recipients are eligible for
$2,500 to fund projects. In addition, individual recipients are given public
recognition and a personalized plaque.
Cath PCI Quality Support Team
Charlottesville, Va.
University of Virginia Health System
The high-risk nature of diagnostic and treatment
options for cardiovascular patients demands ongoing review. Thus, in November
1994, a collaborative practice team was charged with developing an outcomes
management model for patients undergoing cardiac catheterizations or coronary
interventions.
The team consisted of representatives from
relevant areas, including physicians, nursing, pharmacy, utilization review,
social work, nutrition, respiratory care, chaplain, clinical laboratory, finance
and administration. Multiple task forces worked simultaneously to analyze
processes and achieve a working model.
After reviewing comparative regional and
national data and analyzing the scientific literature, our team concluded that
we had opportunities for improvement of both financial and clinical outcomes.
Because practice variations existed among the disciplines in five different
geographic regions of our hospital that cared for this patient population,
several practice changes were necessary as part of the improvement process.
Data from the three-month pilot period showed
that the highest variances were those surrounding the new practice changes.
Investigation revealed that clinicians were fearful of the changes in practice
and were more comfortable with the known protocols of care. Through education
about how the outcome model was grounded on research supporting the efficacy for
the practice changes without an increase in complications, the staff became more
comfortable following the clinical pathway and orders.
The impact of this initiative has been
multifaceted. The synergy that emerged when dedicated and knowledgeable
disciplines came together to improve one aspect of a process of care transcended
into numerous improvements that encompass the entire continuum of care.
Prevention First-Special Kids
Charleston, W. Va.
Charleston Area Medical Center
The Prevention First Program at Women and
Children�s Hospital is an idea that has grown. We started the program with the
idea of providing more consistent care for children with special needs. These
children often had multiple disciplines involved in their daily lives, and the
only people who knew all these aspects of care were the parents. The problem was
that, in an emergent situation, the family members could not supply this
information, or at least not enough of it to satisfy the needs of the
hospital/facility. In addition, these children were frequently readmitted, which
further complicated their care and was a detriment to normal growth and
development. Another problem was that this increased the financial burden on the
family and the admitting facilities. For this reason, our initial plan was to:
� Identify the children with special needs.
� Make a notebook that would list all
medications and past medical history, as well as special identified needs that
would be specific for each patient, including parent interviews. We would also
obtain consent from the family to be a part of this project.
� Obtain a list of disciplines that would need
access to the information, including the areas in the hospital that would be
caring for the child.
Our research has shown a marked decrease in our
readmissions, as well as a significant cost decrease since the inception of the
program. However, because the level of work involved in updating the books has
been astronomical, we have made plans for the future to include:
� Having one notebook available to the parents
at each hospital or office visit. This notebook would be updated, and the
information kept in one place. This would also make the parents more involved
and responsible in their child�s care.
� Adding another case coordinator to the
program, especially for follow-up and home visits.
� Updating our list of patients who meet our
program criteria.
We hope to research our progress, both in cost
and inpatient time within the next year. We also want to do long-term follow-up
regarding the future development of these children and the impact they have on
society.
Heart Failure Intervention Team
University of Texas Medical Branch
Galveston, Texas
The Heart Failure Intervention Team focuses on
the complex needs of congestive heart failure patients and their families,
applying principles of multidisciplinary collaboration. The team was formed in
response to institutional data that revealed CHF as a primary cause of hospital
readmissions, emergency department visits and economic burdens for both the
hospital and the patients. Our data indicated that 51% of CHF patients had
inadequate financial resources to afford discharge medications and 53% were
admitted because their treatment was not optimized.
The HFIT team was established to address the
needs and optimize the care of these patients. The team consists of
cardiologists, advanced practice nurses, a cardiac rehabilitation nurse, a
dietitian, a social worker, pharmacy clinical specialists, the chaplain, a
respiratory therapist and a physical therapist. Each member evaluates the
patient and provides individualized education and counseling based on the needs
identified. Barriers to learning are identified, and education is provided on
disease process, compliance with medication, diet, daily weights and clinical
follow-up. Resources, activity level and self-care skills are assessed. Funding
issues are reviewed and resources activated to assist non- and underfunded
patients. Scales, pillboxes and a CHF medication diary are provided. A clinical
pathway was developed as a guideline for patient care.
The APN serves as the team leader at weekly
meetings to discuss recommendations for changes in patient management. Regular
telephone follow-up is carried out to check on compliance with medication, diet
and daily weights. Follow-up also is done through clinic visits, communication
with home care agencies, primary care physician contact and cardiac
rehabilitation. A home health CHF clinical pathway is used.
The results are improved patient satisfaction,
improved quality of life, reduced CHF readmissions and emergency department
visits and improved survival rate. These outcomes are especially evident in
underprivileged and nonsponsored patients.
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