Innovations in nursing practice.
According to the Webster Dictionary, innovation is defined as the introduction of something new, a new idea, method, or device. At UC Irvine Healthcare there is a focus on innovation. Innovation is encouraged in each employee throughout the organization and reinforced through the organization's recognition program.
Our foundation is established through our mission, vision, and values which defines who we are as an organization and identifies our expectations. The corresponding support structures begin with our mission, "Discover. Teach. Heal." and our vision to be among the best academic health centers in the nation.
Our values are the behaviors we live by and innovation has been selected as one of our core values. Innovation is promoted and considered the responsibility of all staff, everybody has a role in moving UC Irvine Healthcare to the next level. Innovation is demonstrated by the willingness of staff to share new ideas and concepts with the goal of improving the patient experience, quality of care, and creating a healthy work environment.
Innovation is celebrated and rewarded through the ARISE employee recognition program which began in 1999. The ARISE Award was implemented as a way to recognize outstanding performers who exemplify our medical center's core values - Academic, Achievement, Respect, Integrity, Service and Excellence. In 2010, the ARI2SE recognition program was revised to reflect the organizations focus on the following values: Accountability, Respect, Integrity, Innovation, Service, and Excellence. Attributes that define the Innovation category are "new ideas and/or approaches that can change the way the world discovers, teaches, and heals."
The organization has ensured the structure is in place to enable innovative ideas to be brought forward. Examples of these structures include organizational and nursing committees, the clinical ladder and the incentive program. Innovation is seen at all levels of the organization from the bedside nurse to the executive leadership team.
The revitalized shared governance structure lends itself to ensure the ideas of the staff are brought forward and vetted at the right committees. An example of an innovative idea being brought forward through the shared governance councils is the Nurse Research Fellowship program. The fellowship was proposed as a way to encourage frontline nurses to become more involved in nursing research. The idea was presented at the Nursing Quality and Research Council (NQRC) meeting. The chair of the NQRC brought the proposal to the Coordinating Council. After discussion, the Coordinating Council requested changes to the proposal that would have a dramatic impact. The response from the Coordinating Council was reported back to the NQRC and further discussion ensued. The NQRC prepared a response back to the Coordinating Council, voicing concerns regarding the suggested changes and the rationale of these concerns. The Coordinating Council listened to the staff and accepted the proposal with only minor changes.
Light Protection Dome: Protecting the Preterm Infant and Maintaining a Safe Environment:
A recent trend in neonatal nursing includes the provision of a darkened environment to protect very preterm infants from ambient lighting. To achieve this, many neonatal units have mandated a darkened work environment. Although potentially advantageous to preterm infants, a darkened environment makes visualizing the infant more difficult and increases fatigue in health care workers, especially those working at night. Research has demonstrated reduced alertness and increased errors when healthcare workers provide care in a continuously dimmed environment.
Other alternatives have not proven successful. Infants have an aversion to anything directly placed over their face and head, therefore efforts to cover the neonate with a lightweight blanket were unsuccessful. Covering the incubator or open warmer were not feasible for a variety of reasons including the difficulty with keeping the cover in the correct position and the potential to limit the visibility of the infant.
Two NICU nurses collaborated to design a device that would protect the infant while allowing the medical team to work in a safe environment. The recently designed "light protection dome" has been implemented in the NICU to find a balance between the needs of the preterm infant for a darkened environment and the needs of the healthcare worker for a variably lighted environment. This dome lined with black out material and designed to flex in different positions to assure appropriate light protection for the patient has resolved the problem. To document the success of the design, nurses obtain light meter readings with the dome in place. The results consistently demonstrate a reduced light level (1-3 lux) while in use despite the ambient light level readings of 20 lux.
This innovative device has been widely accepted by the NICU staff, patient and families.
Planning of Care
The planning of patient care is an essential part of nursing practice, but often the cumbersome process was regarded as a waste of time or useless task. At UC Irvine Medical Center, care planning is viewed as a tool to provide a "road map" to guide all who are involved with a patient's care. To be effective and comprehensive, the care plan must inform all individuals involved in the care of the patient to ensure the appropriate care is provided and optimal outcomes are achieved.
In collaboration with frontline staff, Cheryl Simkins, Clinical Nurse Educator for Critical Care, developed a new planning of care tool. The goal was to develop a plan of care that was effective in driving the care delivered to the patient, was easy to initiate, individualize, meet all regulatory requirements and continue to meet all of the professional requirements delineated in the American Nurses Association Scope and Standards of Practice. The resulting care plan achieved all of these objectives. Staff feedback on the new care plan included:
- "One stop shop, felt like it focused on the big picture and less consumed on getting paperwork done."
- "More concise, comprehensive."
- "Gives a whole picture on the flowsheet."
Staff champions made a huge impact on the success of this transition and their innovative plan resulted in a more comprehensive care for the patient. The overall project and actions are detailed in EP7EO.
Patient Satisfaction with Pain Management:
A multidisciplinary team focused on improving the patient's experience and overall satisfaction, specifically on pain control. The committee used Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data and identified four low performing units. In order to understand the issues surrounding pain control the committee members went to the customers: patients, nurses, and physicians to ask predetermined questions, conduct focus groups and complete surveys.
From the focus groups, a reoccurring theme was lack of communication. Pain perception and the communication of that pain seemed to be confusing for the patients and practitioners. Using the typical numeric pain scale 1- 10, it was identified that patients did not fully understand how to rate their pain. A score of four to one patient may have been a 10 to another patient. Practitioners sometimes did not believe the patient's report of pain, because the patient's body language did not fit that pain number according to the practitioner's belief.
The committee's first steps to improving patient satisfaction surrounding pain control focused on improving the communication with the patient regarding pain management. Nursing members of the committee developed two innovative tools (Exhibit NK8-3). A pilot project is currently underway on all four identified units and outcome data has demonstrates favorable results. The tools are posted in the each of the patient rooms and have successfully increased the conversations with the patient, nurse, and physician regarding pain management. The plan is to implement these tools house wide.
The OB Hemorrhage Clinical Nurse III project, discussed in EP31, resulted in several innovations. The program, designed to look broadly at the problem of obstetrical hemorrhage and to develop and implement a standardized approach to prevent and/or treat an obstetrical hemorrhage, resulted in numerous improvements.
Throughout the process, coordination with key departments occurred to develop the following: OB Hemorrhage Risk Assessment, Trauma Registration for Obstetrical Patients (Doe Packs), Blood Requisition and Transfusion Protocols for Obstetrical Patients and an Obstetrical Hemorrhage Algorithm.
The most innovative and valuable tools that came out of this project were the OB Hemorrhage Cart (Exhibit NK8-4, Exhibit Nk8-5) and the OB Hemorrhage Risk Assessment. The program was implemented in April 2010 and during the last accreditation survey, the Perinatal department was recognized as having a best practice for preventing and treating an obstetrical hemorrhage.
This innovative project demonstrates the impact a team with a bedside nurse champion, can make to improve patient care and outcomes.
Utilization of a Personal Safety Assistant (PSA)
The Medical-Surgical leadership team recognized that the use of sitters escalated each year, due in part, to goals of patient fall prevention. A performance improvement project in the utilization of sitters was undertaken. The purpose of the project was to assure the appropriate assignment and utilization of the sitters through the application and justification of clinical decision-making regarding patient and staff safety and leadership oversight. The use of nursing assistants staffed one to one for patient safety needs was not clearly defined prior to 2010. The Full Time Equivalents (FTEs) provided grew rapidly and there was not a defined process for either implementing a sitter and for discontinuing a sitter.
The Medical-Surgical team reviewed evidence based practice and created a new policy "Utilization of a Personal Safety Assistant (PSA)." The sitter position was renamed the Personal Safety Assistant (PSA) and an innovative PSA Assessment Tool was developed. The tool includes assessment of the effectiveness of alternative measures attempted prior to the request.
To identify staffing needs, the frontline nurse determines if the patient meets the criteria for a PSA by completing the PSA Assessment Tool.
The new policy and process, implemented in 2010, has resulted in a standardized process for determining the patient's need for a PSA and has decreased the patient fall rate which is now under the CALNOC mean (Exhibit NK8-6).
This innovative tool and approach to staffing has improved the patient outcomes related to falls while also providing clarity for staffing.
Pilot for neuroscience bedside nurse screening of stroke patients for swallowing in stroke patients
Dysphagia is clinically present in 42% to 67% of patients within the first 3 days of stroke, and the incidence of aspiration within the first 5 days ranges from 19.5% to 42%. Because pneumonia in stroke patients is often the result of aspiration, systematic use of a dysphagia screen can result in a significantly decreased risk of pneumonia and an improved general outcome.
"Get with the Guidelines," a hospital-based quality improvement program coordinated by the American Heart Association (AHA) and American Stroke Association (ASA), has chosen dysphagia screening as an important indicator for quality improvement in stroke programs. A swallow screen is required before a patient takes anything by mouth, including medications. Because nurses assess a patient upon admission, UC Irvine decided that nursing assessment would be most appropriate method for the screening, as opposed to waiting for the occupational therapy assessment. The Massey Bedside Swallow Assessment is endorsed by the ASA for a nursing bedside swallow assessment. UC Irvine Healthcare developed a bedside Swallow Assessment tool based on the Massey swallow assessment for neuroscience nurses.
Goals of the swallow screening program are:
- Develop a Nursing Bedside Swallow Screen Tool to triage stroke patients at risk of aspiration/dysphagia
- Early detection or risk of dysphagia
- Prompt decision making regarding the presence or absence of dysphagia
- Trigger timely referral for speech and language therapy assessment, as appropriate
The Stroke RN collaborated with Speech Therapists to develop a course to train the neuroscience nurses. The goal of the course was to provide the theoretical knowledge and practical skills to be competent to carry out a basic swallow screen to stroke patients.
All neuroscience nurses attended one of the swallow screen classes offered. In addition to the class training, nurse swallow screening champions were identified. These champions were vital to ensure the nurses were screening the stroke patients correctly. Attachment NK8e, Nursing Bedside Swallow Screen for Stroke Patients PowerPoint
The pilot bedside swallow screening began in March 2012 with evaluation of the program pending. The nurses will provide feedback on the screening form as it relates to their workflow, ease of applying the screen, and considerations/suggestions on modifications of the form.
When dysphagia is identified soon after a stroke, treatment can be started, and the risks of aspiration and malnutrition can be diminished. Nurses play an important advocacy role in caring for a patient with dysphagia. By identifying swallowing difficulties, nurses can advocate for necessary services for the stroke patient and collaborate as patient and family educators in the treatment of dysphagia. Utilizing nurses for this screening is an innovative practice that benefits the patient.
Innovative nursing projects often come from bedside staff that are observing care at the bedside for extended periods, are providing direct patient care to patients, and consistently interacting with patient and families. These types of innovations are often utilized as Clinical Nurse III (CNIII) projects which is a required step on the clinical ladder advancement from CNII to CNIII. The following are examples of problems and/or challenges identified at the bedside by nurses and then developed into innovative Clinical Nurse III projects.
Identifying Congenital Heart Disease in the Normal Newborn using Pulse Oximetry
Congenital heart disease (CHD) is the most common birth defect and is detected during either the prenatal or postnatal period. Prenatal testing, is an important early screening mechanism for life threatening heart disease, however diagnosis is made in only 23% of pregnancies or 11% of live births. Detection during the postnatal period is currently done by either physical examination, or by detection of symptoms during the first 24 hours of life. These methods have proven to be successful in identifying only 50% of infants with CHD. Failing to detect critical CHD while in the newborn nursery may lead to serious events such as cardiogenic shock or death. Early detection of critical CHD can potentially improve the prognosis and decrease the mortality and morbidity rate of affected infants. The use of Pulse oximetry in the normal newborn has proven successful in detecting some forms of critical CHD in the newborn nursery. The goals of this Clinical Nurse (CN) III project, conducted by a Barbara Williams, Clinical Nurse II, were to:
- Establish guidelines for informing, educating, and training providers and staff in the perinatal department
- Update Standardized Nursing Procedure (SNP) to include pulse oximetry prior to discharge
- Collaborate with the Information Services Department to update current order set for SNP
- Screen all infants prior to discharge
This CN III project introduces an innovative approach utilizing pulse oximetry ordered by the frontline nurse using a Standardized Nursing Procedure that will help to identify infants with critical CHD and low levels of oxygen in their blood before an infant presents with symptoms.
According to the Institute for Health Improvement and the Surviving Sepsis Campaign, severe sepsis carries with it a mortality risk between 30 % to 50 % and in the setting of shock, this rate is even higher. More than 750,000 cases of severe sepsis occurred annually during 2000. Sepsis can rapidly progress to severe sepsis shock and, within 24 hours, it can harm and kill patients if not treated quickly. Sepsis increases ICU length of stay and its associated costs. The use of algorithmic processes leads to better outcomes. The goal of the project, initiated by Florence Zilko, CNII in the Surgical Intensive Care Unit, was to develop a Sepsis Response protocol to help identify patients in early sepsis, facilitate utilization of a sepsis resuscitation bundle, and reduce the mortality rate.
In order to improve severe sepsis detection and management, a Sepsis Response Team (SRT) convened and the following resulted:
- Sepsis screening tool
- Order sets that include drugs, laboratory measures and bundle interventions
- Algorithm when the order set is initiated
- Completion of sepsis resuscitation bundle within 6 hours on ICU patients with severe sepsis, septic shock, or lactate > 4 mmol/L
The innovative screening tool and algorithm are currently in use and data collection is underway.
Reducing Unplanned Extubation in the Neonatal Intensive Care Unit
Unplanned Extubation (UPE) had become a growing concern in the Neonatal Intensive Care (NICU) beginning in 2008. Methods to identify and track these events had been developed and a variety of practice changes had been instituted including modifying endotracheal tube securement methods and requiring two people for specific types of handling, however the UPE rate had remained unchanged (average 5.4/100 ventilator days).
Kerri Burros, CNII in the NICU, interested in working on her Clinical Nurse (CN) III project, identified UPE as her project choice. She reviewed the literature and the past work completed on UPE and determined that a staff survey might provide new information and new interventions. She developed and administered a staff survey looking at staff attitudes about UPE along with identifying staff ideas about how UPE reduction could occur. Identifying staff attitudes about UPE was a new concept. This innovative approach to process improvement revealed some interesting data.
Through her survey, Kerri demonstrated several barriers to reducing UPE including:
- The staff did not believe or understand the negative impact of UPE on the infant. This belief may have been due to the number of infants not re-intubated or the ease of which re-intubation occurred.
- The staff was not aware of all UPE events or the rate of UPE. Although events were reported, they were not shared with a larger audience and many learning opportunities were lost as a result.
- There was a lack of an identified team with a focus on reducing UPE in the NICU.
Kerri completed many things during her project including:
- Asking staff members to join an UPE team with a focus on developing awareness of UPE, analyzing events, and making recommendations to reduce UPE in the NICU
- Posting of "days between events" to increase staff awareness of UPE occurrences.
- Sharing the analysis of all UPE events with the staff as "lessons learned"
- Develop, administer, and analyze the results of the staff survey. Share the findings of the survey with staff.
The results of the project demonstrated an increased awareness of the staff about UPE events and identified areas for further study, including a retrospective review of all UPE events and the potential effects on length of stay, ventilator days, chronic lung disease and other morbidities. Other noteworthy results included 80 days between UPE events which had not occurred before, overall reduction of UPE events (2 UPE/100 ventilator days), and an increased staff awareness of UPE. Utilizing the innovative approach of determining the staff's perceptions of an issue led to a targeted education program with unique interventions.
Bereavement in the NICU
Providing bereavement services to parents and families of patients in the NICU can be challenging for staff. Although all staff receives information, lectures, and other training regarding bereavement, the staff continued to be uncomfortable about the processes and care involved. Frequently, when it was determined that a baby would be taken off life support, many nurses would verbalize a lack of skills and knowledge about the best methods to support families during this time along with concern about the details of the infant's care. Nancy McCall, RN in the NICU has a passion for this aspect of care and was known as an informal resource in this area. As such, she was interested in creating a comprehensive and multidisciplinary approach to education about bereavement in the NICU.
Nancy's Clinical Nurse (CN) III project's goals included increasing the staff's knowledge and skills in providing bereavement care in the NICU. Her focus was specifically on hands-on care of the infant and providing family support. Nancy performed a literature search to determine if there were model programs for this type of education. Although they are many programs that spoke of palliative care, Nancy did not find the specific information she was looking for such as:
- What nurses can do when a decision is made to discontinue life support
- Care of the family
- Creation of a bereavement checklist
- Preparing the body
- Creating family mementos.
Nancy developed a staff survey to identify the learning needs of the staff. She then created a bereavement hands-on station that included bereavement resources, how to create handprints/footprints and other mementos, preparing the infants, and completing required paperwork. She used the same survey with the staff to measure the effectiveness of her educational efforts. The results showed that the hands-on station was very effective, with the overall comfort levels of the staff increasing as demonstrated in her final project presentation.
Nancy's project continues with all new hires in the NICU receiving similar hands-on education about bereavement services.
Innovation is about doing things differently or doing different things to achieve large gains in performance. Innovation in practice is imperative in order to improve patient safety and quality care. As demonstrated in the examples provided, many innovations come from staff working at the frontline. Nursing leadership sees innovation as a skill that everyone in the organization can master and is proud to support the frontline nursing staff working to solve common issues through the creation of innovative solutions. Innovation in nursing is happening and making significant contributions towards improving the care provided to the patient.
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