ValleyCare Nurse: ValleyCare Nurse Spring 2011 Edition 3

ValleyCare Nurse
Spring 2011 Edition 3
On the Path:
Evidence Based Care
at the Bedside
TABLE OF CONTENTS
From the Chief Nursing Officer…
Page
1
Jessica Jordan RN, BSN, MS, CIC
Meet the Nurse Research Council
2
Achieving Door to Balloon Times
4
Karen Dynek MSN, RN, CCRN, ACC-CCA
Progressive Mobility
7
Angelina Daco RN, CCTN, CCRN
Intradermal Lidocaine: Nurse Perceptions and Barriers for Practice Implementation
8
Erin Bashaw MSN, RN-C and Jolene Duffey BSN, RN
Highlights from Maternal Child Safety Program
10
Shelley Barnhill, RN-C, BSN, MA and Gina Teeples, RN-C, BSN
A Red Sash for Safety: A Review of Observational Research Findings
13
Jeanette Kitt BSN, RN, CCRN
Rapid Response Team Success
14
Barbara Murphy BSN, RN
Fusion of Magnetism and Just Culture
Erin Bashaw MSN, RN, CNE
15
From the Chief Nursing Officer
Jessica Jordan RN, BSN, MS, CIC
Chief Nursing Officer
Our third edition of the ValleyCare Nurse Magazine focuses on Nursing Evidence-Based Practice, Research and
Innovation. While you read our Spring edition you will meet the members of our Nursing Research Council. You
will also have the opportunity to read articles written by direct care nurses, which are the result of many
opportunities offered through ValleyCare. In 2006, Nursing sponsored the first Nursing Research Contest and
this was kicked off with an educational session on Evidence-Based Practice by Jessica Jordan. The following year
Dr. Faye Bower, from Holy Names University, presented on Nursing Research and in 2008 we joined the UCSF
Center for Nursing Research and Innovation which provided a three-part Clinical Research Series. These courses
enabled our direct care nurses to further hone their skills, research the “burning questions” of their practice in
their areas of specialty, design projects and document their outcomes.
There could be no better time to make this the subject of the ValleyCare Nurse Magazine since Nurse’s Day, which
is celebrated around the world, commemorates the birth of Florence Nightingale. Ms. Nightingale not only was
the “Lady with the Lamp” who gave care and hope to the soldiers she served, she was a pioneer in the visual
presentation of information and the use of statistical graphics. She used the Nightingale Rose Diagram to illustrate
seasonal sources of patient mortality in the military field hospital she managed. Nightingale called a compilation of
such diagrams a "coxcomb". She made extensive use of coxcombs, to present reports to Members of Parliament
about the conditions of medical care in the Crimean war.
ValleyCare Nurses do amazing work and have shared their results to colleagues outside of ValleyCare at venues
such as VHA, Beacon, and other Professional organizations We have made vast strides in: Improving Door to
Intervention Times for STEMI Patients, Improving Out- of- ICU Code Blues with the Rapid Response Team,
Reducing Ventilator Associated Pneumonias with Protocols for Ventilator Care, Reducing Sepsis Mortality with
Early Goal Directed Sepsis Protocols, Improving Neurological Outcomes in Cardiac Arrest Patients with the
Therapeutic Hypothermia Protocols and Reducing CHF Readmissions. All of these and more have been nurse
driven, collaborative partnerships designed to reduce morbidity and mortality for our patients.
In this era of healthcare reform with an increasing focus on the use of evidence-based protocols, nursing research
has never been more important to help guide our practice and improve our patient’s outcomes. Nurses will be at
the forefront of healthcare reform, however it ends up looking, not only because of our competence and
compassion but also because of our desire to continually improve the care of our patients.
If Ms. Nightingale could do this while working with thousands of soldiers in her care, we can and should follow in
her footsteps to improve and share our nursing practices through research and innovation. Happy Nurses’ Week
and thank you for everything that you do for our patients each and every day.
!
!
!
!
Sincerely,
Jessica Jordan
1
VALLEYCARE NURSE MAGAZINE SPRING
Meet the Nurse Research Council
ValleyCare nurses have a long history of interest and active participation in research. Clinical trials (ISIS and GUSTO)
conducted during the mid 1980’s with thrombolytic medications for the treatment of suspected myocardial infarction patients,
solidified the interest ValleyCare nurses had to participate in data collection and eventually conduct research of their own.
In 2008 the Nursing Research Council was formed. Original members were all Master’s degree prepared and spent time
developing the Research Council Charter, Policy, a research and evidence-based practice framework, internet website for
Nursing Research and production of the Research Council Publication. All of the groundwork was designed to offer
information and guide the research process for the direct care nurse providing patient care. This group is dedicated to advance
the professional practice of nursing through scientific inquiry, use of evidence-based practice and practice integration of
relevant nursing research for ValleyCare Health System.
Early collaboration with UCSF assisted the Research Council members with education and guidance through the research
process. Classes offered to nursing staff by the UCSF nurse researchers encouraged the professional nurse to explore evidencebased practice and design studies to experience the research process. From these classes many studies developed. Clinically
induced hypothermia, use of lidocaine infiltration for IV starts and how to encourage staff to adopt the practice, early
ambulation for ventilator dependent patients, family visitation in the PACU are just a few of the many subjects being explored.
Participating nurse’s are excited and motivated and the Research Council looks forward to active participation from the
professional nurse at the bedside.
The Members:
Martha Brown MSN, RN, CPAN(Chair) has been an RN for the ValleyCare Health system
since 1980. As an RN in the ICU and Emergency Department she learned about how actions by the
nurse influence patient outcomes and has been excited to see how the tremendous increase in
evidence- based practice going on at the bedside. We no longer are tied to doing a task “just
because” but are recognized for finding a better way and proving it! As Nurse Manager for
Perioperative Services for the majority of her career, Martha has seen the tremendous change and
advances that have been made to influence the safety and wellbeing of the surgical patient
population. Something as simple as making sure the patient has a normal temperature when they go
into surgery can improve their ability to heal. It is these kinds of changes that can have a big impact,
and I applaud the profession of nursing for recognizing how important it is for all of us to participate
in the quest to provide our patients with safe and evidence-based care.
Shelley Barnhill BSN, MA, RN-C (2008- 2011 Chair) has worked in perinatal nursing for over 25
years and currently works in Maternal Child as the Perinatal Educator. Shelley is an ACLS, BLS and
NRP instructor and certified in Inpatient Obstetrics and Electronic Fetal Monitoring. Shelley’s passion is
perinatal safety, working towards optimizing healthy outcomes for mothers and their babies. Shelley had
the opportunity to travel to Azerbijian and Kosovo, with ValleyCare Health System and American
Internation Health Alliance, and teach nurses and doctors neonatal resuscitation. It was an opportunity
of a lifetime and showed that education and training are essential to providing safe care anywhere in the
world. Shelley and MaryKay Dunn developed the Evidence-Based Education Module on the Research
Council webpage. Shelley is excited to see nurses bringing evidence to the bedside!
Erin Bashaw MSN, RN-C has a Masters in Nursing Administration and a B.S. in Health Science. She is working on completing her Doctorate in Nursing Practice. She has worked in healthcare for
nearly 15 years. Before coming to ValleyCare in 2004, Erin worked at Alta Bates as a C.N.A. and ward
clerk on a 60- bed surgical unit. Erin is passionate about transforming leadership relationships with
bedside care givers and administration, creating the next generation of healthcare leaders and increasing
bedside autonomy for all nurses as a professional practice. She believes that happy nurses are able to
provide exceptional care which equals happy patients and better patient outcomes.
2
Mary K. Dunn MSN, RN. I have been a nurse for 28 years, 22 of those employed with ValleyCare
Health System. I have worked in ICU, PACU and Preop Testing throughout my career. For eight years,
I have been in the Nurse Educator role, first in Periopertive Services and presently with Staff
Development. I have always been interested in finding inventive ways to provide education and access to
evidence, for the direct-care nurse, working with new technologies like video and the web. This interest
has remained a focus for me on the Research Council. How do we as a council help the direct-care
nurse gain easy access to literature, guidelines and standards in their work day? Not only for quick
reference, but to stimulate ideas for evidence-based research projects. Please come join us during these
exciting times.Twitter anyone? !
Karen S. Lounsbury DNP, RN-BC In 1989 when I began my career at ValleyCare it was in
Critical Care. I was fortunate to be a member of the Thrombolytic Task Force during the days of the
GUSTO and ASCENT studies and collected data for those studies. During the Doctor of Nursing
Practice program at the University of San Francisco, I was reintroduced to Research through an
Evidence-Based Practice class. When the Research Council formed in 2008, I wanted to be part of this
exciting new Council. The three Evidence-Based Practice classes provided by the Center for Nursing
Research & Innovation from the University of California San Francisco were wonderful. We were able
to develop our PICO questions, receive feedback from the consultants and other participants. The
Toolkit the Nursing Research & Innovation consultants developed for us is very useful for our projects. Janine Pinks NP, PA-C, MSN has a diverse professional background with 23 years of nursing
experience. I have worked in several areas of nursing including the emergency room and neonatal
intensive care. The last 17 years I have specialized in adult open heart surgery and the last eight years
has worked as an advanced practitioner. I have been involved in the startup and participate in many
public education programs on heart disease. I am also involved in staff development and education. I
joined the research council because it is important that we stay current and practice evidence-based
nursing to ensure that our patients continue to have the best possible outcomes. I earned my Masters of
Science in Nursing at the University of California, Sacramento, and FNP/PA Certification at
California State University, Davis.
Bernie Revak RN, MSN, PHN, CIC. I have been a nurse at ValleyCare since 1981, working in
almost all areas of nursing and the hospital including clinical and non-clinical areas. I am the Director
for Infection Control, Public Health, and Outpatient Clinics. Infection Control is so challenging in the
current climate of healthcare with all of the emerging super bugs and increasing regulatory mandates.
Being board certified in Infection Control and Prevention and actively participating in the local chapter
of Association for Professionals in Infection Control and Epidemiology (APIC) helps manage the
unpredictable world of emerging infections. Focused on getting the message of prevention to staff for
minimizing the transmission of healthcare infections and providing safe patient care, “Gel In and Gel
Out” is the mantra.
MaryJo Schaarschmidt MSN, CPNP, CNS, RNC-NIC, earned her BSN from the University of
San Francisco, her MSN at UC San Francisco and her post graduate PNP at Indiana University Purdue
University. During these past 8 years at ValleyCare, MaryJo has acted as the CNS for the NICU and
Pediatrics. She helped with the NICU renovation and pediatric partnership with UCSF.
Process improvement, measures to increase patient safety, mentoring, staff education, and program
development are all guided by Evidence-Based Practice. Highlights of EBP within the Maternal Child
Department here at ValleyCare are: national recognition for our program that allows nurses to initiate
BiliChecks on all babies with a systematic approach to identifying and treating hyperbilirubinemia;
medication safety measures put in place house-wide for all pediatric patients such as the syringe pump
with medication library, weight-based ordering with pre-printed orders sets and standardized medication
concentrations, and independent double checking between MDs, pharmacists and nurses; minimizing the availability of heparin
in the NICU; simulation-based training for high risk deliveries, neonatal resuscitation and pediatrics emergencies; and
TeamSTEPPS training allowing for increased communication and role development between multi-disciplinary services.
3
VALLEYCARE NURSE MAGAZINE SPRING 2011
Achieving Door-toBalloon Times: Medical
Center Teamwork
Strategies
Karen Dynek MSN, RN, CCRN, ACC-CCA
An ST elevation myocardial infarction
(STEMI) is a life-threatening emergency,
often a sign that a
major coronary
artery supplying
blood and oxygen to
the heart muscle is
100% blocked. Time
is muscle. Rapid
recognition and
triage of these
patients to
percutaneous
coronary
intervention (PCI)
reduces mortality
and morbidity.
Strong teamwork
and communication
from emergency
medical services
(EMS) to the
Emergency
Department (ED) to
the Cardiac
Catheterization Lab
will ensure a safe and rapid triage to lifesaving PCI.
BACKGROUND:
ValleyCare Health System has a long
history of focus on the care of STEMI
patients. In the mid-1980s, ValleyCare
participated in cutting-edge thrombolytic
research studies such as ISIS for
streptokinase and GUSTO for tPA (tissue
plasminogen activator). Both
streptokinase and tPA are clot-dissolving
drugs. A foundation for our current
practice was built then, with an
appreciation for the importance of
identifying the critical intervals of doorto-data (ECG), data-to-decision, and
decision-to-drug.
In 1995, ValleyCare began participation
in the National Registry of Myocardial
Infarction (NRMI) which continued for a
decade and eventually evolved into the
current American College of Cardiology
(ACC)/American Heart Association
(AHA) ACTION-Get With the
Guidelines myocardial infarction registry.
Core measures and national guidelines for
care of the myocardial infarction (MI)
patients are developed based on the data
collected from those registries, truly
evidence-based practice.
In 2000, ValleyCare moved forward with
a plan to treat STEMI patients with
primary PCI. This reflected the national
move away from primary thrombolytic
therapy to balloon angioplasty and stents
based on ACC/AHA guidelines.
ValleyCare did not have cardiac surgery
at the time, so a proposal was made to the
California Department of Health
Services that ValleyCare go forward with
primary PCI with no cardiac surgery on
site. The proposal was written by the
Cardiac Resource Nurse and approved by
Senior Administration. State permission
was granted, and ValleyCare became one
of very few centers in the United States
and California to provide this service.
Using the lessons learned from our
experience with the thrombolytic studies,
we focused on building teamwork and
communication between the ED, Cath
Lab, and CCU. We looked at the time
intervals; door-to-data (ECG), data-todecision (Cardiac Team Alert), decisionto-Cath Lab, and overall door-to-balloon
(angioplasty). A timeline sheet was
4
developed which serves as a nursing and
physician order sheet for the preparation
of the STEMI patient for PCI from the
ED to the Cath Lab. The timeline sheet
has been edited over time to reflect
evidence-based changes in care. Our
focus is on process and how to best make
the process work so we provide safe and
rapid care to our STEMI patients. We
successfully treated
our first Cath Lab
STEMI patient with
PCI in October of
2000.
In 2003, researchers
from the Yale New
Haven Center for
Outcomes Research
and Evaluation
contacted ValleyCare
regarding our
consistently excellent
treatment times for
STEMI patients
based on NRMI
data. ValleyCare
became one of
eleven United States
hospitals profiled in
the manuscript
published in The
Journal of the
American College of Cardiology (JACC)
in 2005 “Achieving Door-to-Balloon
Times That Meet Quality Guidelines:
How Do Successful Hospitals Do
It?” (Hospital names are blinded in the
article but a researcher verified that
ValleyCare is hospital #10.)
In October of 2005, ValleyCare Medical
Center submitted an application to
become a Cardiac Receiving Center
(CRC) for Alameda County Emergency
Medical Services (ALCO-EMS).
ValleyCare met all criteria under the
Alameda County Health and Safety
Code, Division 2.5, Sections 1797.67,
1798, and 1798.170, and the application
was accepted. ALCO EMS is enrolled in
the American Heart Association’s Mission
Lifeline program which recognizes the
importance of specialized Cardiac
Receiving Centers to provide the best care
for STEMI patients.
In 2007, ValleyCare became a member of
the Door-to-Balloon (D2B) Alliance. The
D2B Alliance grew out of the Yale New
Haven interviews which identified key
factors to achieving door-to-balloon times
that meet or are below the 90-minute
D2B time recommended by the ACC and
the AHA.
management, ED physicians and
Cardiologists, ED and Cath Lab staff, a
representative from CCU, and
occasionally by representatives from
pharmacy and the lab. EMS personnel
are also invited to attend, but as yet have
not. As a group, we analyze every D2B
interval for every STEMI patient and
The icon is red and alerts everyone to a
chest pain patient which must be triaged
and registered immediately. When the
decision is made for a patient to be
triaged to the Cath Lab emergently, a
“Cardiac Team Alert” is paged and the
tracking board icon shows a moving
animated heart.
ValleyCare Quarterly STEMI Door-to-Balloon (D2B) Data
100
90
Number of minutes from Door to Balloon
80
70
60
50
40
30
20
10
0
1Q2008
2Q2008
3Q2008
4Q2008
1Q2009
2Q2009
3Q2009
4Q2009
1Q2010
2Q2010
3Q2010
4Q2010
1Q2011
Number of Cases
12
10
16
9
9
20
12
7
16
12
6
11
19
Median Time
71
71.5
78
78
69
64
64.5
72
59.5
58
61.5
63
58
National Goal
90
90
90
90
90
90
90
90
90
90
90
90
90
ValleyCare Goal
60
60
60
60
60
60
60
60
60
60
60
60
60
These strategies are:
• ED physician activates the Cath Lab
• One call activates the Cath Lab
• Cath Lab team is ready to begin the
procedure within 20 to 30 minutes of
the page.
• Prompt feedback to the ED and Cath
Lab staff about D2B times
• Senior management commitment
• Team-based approach
• Using a pre-hospital ECG to activate
the Cath Lab
METHODS:
In an effort to continually improve our
process, we began monthly STEMI
meetings in January of 2009. These
meetings are attended by senior
make recommendations for improvement
to our process, a reflection of structural
empowerment.
In September of 2009, improving doorto-balloon time for STEMI patients was
identified as a project for the ValleyCare
Performance Improvement team. The
team is chaired by the ED nurse Director
and co-facilitated with the Quality
Management RN. Measurements were
obtained by a current core measure
abstraction process, and a 100% case
review and timeline breakdown by the
Cardiac Resource Nurse. A special icon
for the ED computerized tracking board
was devised and implemented by the
Emergency Department RN Information
Technologist/Database Administrator.
5
To ensure prompt feedback about D2B
times, STEMI bulletin boards are
mounted in the ED, Cath Lab, and
Cardiology reading room. These boards
display graphs showing the D2B intervals
for all STEMI patients. ValleyCare’s goal
is D2B < 60 minutes. “STEMI Stars” are
displayed for each STEMI PCI < 60
minutes. On each STEMI Star are listed
the date, D2B time, and all staff involved
in caring for the patient from EMS, ED,
and Cath Lab. ED and Cath Lab staff
often express pride when named on a
STEMI Star! The ED plans a larger
STEMI board near the ambulance
entrance so that the EMS personnel will
be able to easily view the graphs and
stars. Especially prompt feedback from
the Cath Lab to the ED occurs when the
Cath Lab monitor nurse calls the ED
after the first balloon inflation to share the
D2B time. If they are able, ED nurses and
techs will often watch part or all of the
PCI procedure. The Cardiac Resource
Nurse also provides before and after
pictures of the culprit coronary artery
correlated with the STEMI ECG for the
STEMI board in the ED.
OUTCOMES:
A goal of the STEMI group was realized
when we purchased modems for the
Lifepaks of EMS ambulances serving the
ValleyCare area. Wireless transmission of
STEMI 12-lead ECGs started in March
of 2010. The ED physician activates a
Cardiac Team Alert prior to patient
arrival based on interpretation of the
transmitted ECG. Currently ValleyCare
meets all seven strategies identified by the
D2B Alliance.
For the last three years, ValleyCare
Health System has proudly won a Gold
Performance Achievement Award
bestowed by the American College of
Cardiology (ACC), American Heart
Association (AHA), and the American
College of Emergency Physicians, the
Society of Chest Pain Centers, and the
Society of Hospital Medicine (SHM).
The award is for “improvement in the
treatment of acute myocardial infarction
patients through implementation of
ACTION Registry-GWTG and inhospital initiation of the American
College of Cardiology/American Heart
Association STEMI/NSTEMI Clinical
Guideline recommendations.” The
Cardiac Resource Nurse is now a speaker
for the American Heart Association,
presenting ValleyCare Medical Center’s
strategies for D2B process improvement at
a large conference in Sacramento in
January of 2010 and an East Coast
webinar with a Cardiologist from
Berkshire Medical Center in
Massachusetts in April of 2010.
By using a teamwork approach to focus
on our process, we consistently improve
our STEMI care which in turn leads to a
more rapid time to treatment.
If a Cardiologist is present, a very rapid
Emergency Department triage occurs.
The shortest door to Cath Lab time yet
achieved is 11 minutes.
All members of the STEMI team look for
practical ways to cut several minutes from
the ED to Cath Lab time. Currently the
Cath Lab team arrives, begins Cath Lab
set up, and goes to the ED to retrieve the
patient. We are discussing the possibility
of the ED bringing the patient to the
Cath Lab following a call from the first
Cath Lab team member to arrive. This
would:
• Save time for the Cath Lab
• The ED would transport while the
Cath Lab sets up
• Direct communication between the ED
nurses and Cath Lab nurses would
occur in the Cath Lab
• Critical patient information would be
exchanged very quickly
• Cath Lab and ED nurses would work
together as a team to get the patient
ready
The success of the ED Timeline/Order
sheet led to the development of an order
sheet for the rapid triage of an in-house
patient that develops sudden onset of
chest pain and ST elevation on ECG. The
order sheet was developed and instituted
in 2010.
The monthly STEMI meetings are now
an integral part of the ValleyCare
Medical Center culture and we are
pleased that a plan is in effect to block off
Cath Lab time so that nurses, CVT, and
radiology technologists will be able to
attend during working hours. We are also
pleased that several personnel from
ALCO-EMS will be attending our May
STEMI meeting.
Teamwork, communication, and
committed focus on process are an
ongoing and necessary challenge to
ensure safe and high-quality care for our
STEMI patients. It is a commitment that
we gladly make every day.
REFERENCES:
Alameda County Health and Safety Code, Division
2.5, Sections 1797.67, 1798, and 1798.170.
www.acgov.org.
American College of Cardiology National
Cardiovascular Data Registry (NCDR) - Quality
Measurement for the Cath Lab. www.ncdr.com.
Bradley, et. al. Achieving Door-to-Balloon Times
That Meet Quality Guidelines: How Do Successful
Hospitals Do It? J Am Coll Cardiol 2005; 46:
1236-1241.
Door-to-Balloon Alliance: www.d2balliance.org.
Kushner, et al. 2009 Focused Updates: ACC/AHA
Guidelines for the Management of Patients With STElevation Myocardial Infarction (Updating the 2004
Guideline and 2007 Focused Update) and ACC/
AHA/SCAI Guidelines on Percutaneous Coronary
Intervention (Updating the 2005 Guideline and 2007
Focused Update) A Report of the American College
of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines J Am
Coll Cardiol, 2009; 54:2205-2241, doi:10.1016/
j.jacc.2009.10.015 (Published online 18 November
2009).© 2009 by the American College of
Cardiology Foundation
Mission Lifeline: http://www.heart.org/
HEARTORG/HealthcareProfessional/MissionLifeline-Home-Page
!
STEMI Stars
3/24/2011: Door-to-Balloon = 40 Minutes!!
Congratulations to
EMS:
Damien Burnett EMS
John Fullard EMS
ED:
John Boright MD
Tami Wilson UC
Wayne Poffenbarger RN
Rachel Manning-Harris REG
Luke Slupesky EDT
Cath Lab:
Ayman Hosny MD
Ron Rivera RN
Missy Davis RN
Ebbe Lyttkens CVT
Jesse Pino RT
From the 3rd and 4th quarters of 2008 to
the present 1st quarter of 2011, D2B
times have been reduced by 20 minutes.
6
VALLEYCARE NURSE MAGAZINE SPRING 2011
Progressive Mobility
Angelina Daco RN, CCTN, CCRN
Every specialty of Nursing realizes the
effects of immobility on our patients
both physically and mentally. This
realization has led to the development
of Progressive Upright Mobility
Programs within Intensive Care settings
to improve patient outcomes and
improve overall mobility. These
programs have led to a decrease in
length of stay in Intensive Care, overall
improvement in cardiovascular and
muscle function, stabilization of
hemodynamic measures, decrease in
pressure ulcer rates, and a decrease in
body stress during hospital stay. While
physicians are certainly key stakeholders
in the delivery and creation of
Progressive Upright Mobility Programs,
this is a nurse driven initiative. (De
Jonghe, 2004, p. 1117) (Morris, 2007, p.
19)
intolerance is considered a symptom of
cardiovascular de-conditioning. How
does this happen?Confined to bedrest a
few thing begin to occur for our patients.
There is a 10-20% reduction in
circulating plasma volume which, Kubo
states, “affects
stroke volume and
cardiac
output.” (Akiko,
p. 8) At this time
nursing may need
The complications of immobility are
to replace this
considerable, and each body system
fluid volume and
comes with its own list of complications.
or begin
Table 1 describes the complications of
vasopressive
immobility for each body system.
therapy
Prolonged immobilization, according to
(medications that
Kubo, can cause “cardiovascular
deconditioning” (Akiko, p. 8) in which the raise your blood
pressure) in order
patient’s cardiovascular function
to make up for this volume loss. Though
deteriorates over time due to immobility.
necessary, vasopressive therapy can cause
One can normally see this occur within
further complications throughout the
three to four days of bedrest! Many of
body, thus adding to the length of stay in
our Intensive Care patients with Adult
Intensive Care.
Respiratory Distress Syndrome (ARDS),
Another component of cardiovascular
Sepsis, and other complicated diagnoses
deconditioning is the ability of the body’s
are immobile not just for three or four
days, but for weeks at a time! Orthostatic baroreceptors to stretch and function
properly while immobile.
Baroreceptors are “a sensory
Table 1 Complications of Immobility
nerve ending in the walls of the
auricles of the heart, vena cava,
System
Complication
carotid sinus, and aortic arch,
Pneumonia, atelectasis, pulmosensitive to stretching of the wall
Respiratory
nary embolism
due to increased pressure from
within, and functioning as the
Postural hypotension, cardiac
receptor of central reflex
muscle atrophy, deep vein
Cardiovascular
thrombosis
mechanisms that tend to reduce
that pressure.” (Free Dictionary)
Skin
Pressure ulcers
The function of baroreceptors is
Renal
Calculi, nephritis
to communicate information
Hematological
Anemia
from the smooth muscles within
the vessels to the nervous system.
Gastrointestinal Constipation and fecal impaction
The communication then causes
Glucose intolerance, negative
the body to constrict or dilate
Metabolic
nitrogen balance
blood vessels as we change
position. When we are
Osteoporosis, muscle atrophy,
Musculoskeletal contractures
immobile and don’t change
position, this results in the
Neurological
Depression, psychosis
7
cardiovascular deconditioning described
above. Keep in mind that we are upright
for most of our waking hours and lying
down only while we sleep. The lack of
variation between standing, sitting, and
lying down decreases the amount of
orthostatic movement. When patients
are immobile, orthostatic hypotension
increases which can result in “falls,
labile blood pressure, and other
complications that may increase
hospital length of stay.” (Akiko, p. 8)
Muscle wasting, or musculoskeletal
de-conditioning, is also a complication
of prolonged immobility. When we
are immobile, our muscles lose their
contractility and strength, thus
resulting in atrophy. Up to 1.5% of
! our strength can decline with each
day of
immobility due
to prolonged
bedrest. Our
large muscle
groups utilized
in walking and
upright
movement are
the groups that
deteriorate first
and at the most
! rapid rate!
While it may
take only a few
weeks to lose the muscle strength and
acquire extensive atrophy, it may take
many months of Physical Therapy and
rehabilitation to regain the muscle lost!
(Akiko, p. 8) All the more reason to create
and maintain a Progressive Mobility
Program in the Intensive Care Unit
settings.
Here at ValleyCare, the Intensive Care
Unit Nursing Staff recognized the need
for a Progressive Mobility Program after
attending the Slice of NTI Nursing
Conference in April, 2010. While
working with Dr. Nancy Donaldson as
Evidence-Based Practice Fellows, Renuka
Sivakumaran RN, Lisa Glascow RN,
Phyllis Yau-Chan RN, and Angelina
Daco RN reviewed the evidence for the
use of such a program in our Intensive
Care Units. Much of the evidence
indicated that nursing should not only be
moving the patients into upright positions
for periods of time each day, but that
passive range of motion exercises should
also be performed daily for all joints to
avoid contractures and joint wasting.
(Morris, 2007, p. 3)
While we are still in the design phase of
the Progressive Mobility Program, we are
confident that we can deliver this
important element of care to our patients.
Implementation involves a
multidisciplinary approach to the care of
these patients. Assessing the capability of
our ICU bed surfaces to move into the
chair position was our first consideration
and at this time all of our bed surfaces
have this function. This is key in creating
the head elevation necessary to challenge
the barorecpetors for our immobile
patients. Our Critical Care Medical
Director, Dr. John Yee, has also been
instrumental in his support of the
implementation of the Progressive
Mobility Program. His efforts to research
and communicate the need to our
physician staff are essential as we move
forward with our design and
implementation. We are currently in the
process of meeting with the Respiratory
Therapy Department, the Physical
Therapy Department, and the Critical
Care Unit Based Council to design a
program that will be evidence-based,
sustainable, and successful! Progressive
Mobility Programs require the use of
many resources and sustainability is
difficult to achieve, even for larger
university based hospitals. Your Intensive
Care Units recognize the importance of
this service for our patients and strive for
the goal of sustainability with every
planning phase of this program.
The coming months will result in
continued collaboration and design of
our Progressive Mobility Program. The
complications of immobility are
extensive, however with dedication and
eventual implementation, the Intensive
Care Units will mitigate the effects of
prolonged immobility for our community.
This will result in a decreased length of
stay allowing our patients to go home
sooner! While we here at ValleyCare love
caring for our patients while they are with
us, there is nothing better than seeing
them return to their normal lives at home
with their families! Seeing patients go
home healthy and strong is what why we
work so hard each and every day!
References:
Akiko, K. (). 2008. In Progressive Upright Mobility,
Self Directed Study (pp. 8-9). Kansas University:
Hill-Rom.
De Jonghe, B. (2004). Does ICU-acquired paresis
lenthen weaning from mechanical ventilation?
[Journal]. Intensive Care Medicine, 30, 1117-1121.
Morris, P. (2007). Moving our critically ill patients;
mobility barriers and benefits. [Journal]. Critical
Care Clinics, 23(1), 1-20.
http://medical-dictionary.thefreedictionary.com/
baroreceptor. (n.d).
Intradermal Lidocaine:
Nurse Perceptions and
Barriers for Practice
Implementation
Erin Bashaw MSN, RN-C and
Jolene Duffey BSN, RN
The purpose of this study was two-fold.
The first to identify barriers for practice
implementation of intradermal lidocaine
intradermally bacteriostatic normal saline
with benzyl alcohol versus buffered 1%
lidocaine hydrochloride prior to IV
cannulation, in reducing patient’s pain
and and increasing satisfaction associated
with IV starts. The study found that both
agents were equally effective in reducing
patient’s pain and increasing satisfaction
associated with IV starts.
Approximately 400
bedside nurses
completed the
competency training
for intradermal
lidocaine.
infiltration, used as a pretreatment to
reduce patients' pain, discomfort, fear,
anxiety (while increasing patient
satisfaction with less painful IV starts).
The second focus was to initiate a change
in nursing practice based on current
literature; to provide the nurses with
optional ways of starting IVs to minimize
patients' pain, discomfort, fear, anxiety
and increase satisfaction.
BACKGROUND: The practice of using
intradermal lidocaine for IV starts was
frequently used by nurses in the Pre-op
and Maternal Child/Labor and Delivery
departments. Nurses in these units, often
remarked that patients seem to “prefer”
this method of IV start. Because the use
of intradermal lidocaine was effective in
both reducing IV start pain and
increasing patient satisfaction the
Preoperative Nurses were desirous of
encouraging the practice in all patient
care areas. The Preoperative Nurse
representative on the Nurse Practice
Council brought the idea forward for
discussion. Supporting this was an
internal research project, previously
conducted by the pre-operative
department about the use of
8
The nurses who perform intradermal
infiltration commonly with IV starts; are
comfortable with the technique. The
practice was positively reinforced by
patients positive remarks regarding the
decrease in pain experienced when their
intravenous catheter was placed, usually a
painful procedure.
Based on this information, a study was
conducted to investigate nurse
perceptions about intredermal lidocaine’s
use and barriers for practice
implementation.
RESEARCH METHOD: A descriptive
study was conducted, using a pre-survey/
post-survey design. Both quantitative and
qualitative data was collected. The presurvey sample was collected over a period
of one week in April of 2010 from all
shifts of bedside nurses that were willing
to complete the survey. A total of 100
surveys were returned. The post-survey
sample was collected over a period of one
week in April of 2011 from all shifts of
bedside nurses that were willing to
complete the survey. A total of 71 surveys
were returned.
IMPLEMENTATION: In April of
2010, an educational campaign was
initiated to increase awareness and
complete competency of the standardized
procedure protocol that allowed bedside
nurses to administer intradermal
lidocaine prior to IV starts for the
purpose of minimizing patient discomfort
during the introduction of an intravenous
cannula.
Approximately 400 bedside nurses, over a
period of four months, completed the
competency training and demonstrated
proper technique when starting IVs using
this method. Buffered lidocaine was
stocked on every medical/surgical unit of
the hospital to increase access and
encourage the use. The multi-use vial was
exchanged for a new vial by pharmacy
every 24 hours to maintain effectiveness
and potency of the buffered lidocaine.
Education was reinforced through
occasional check ins with staff, and
encouraging nurses to offer the technique
as an option for IV starts.
RESULTS: The results of the pre-survey
indicated that only 22% of nurses were
aware that using intradermal infiltration
of lidocaine prior to starting an IV is a
standardized nursing procedure. 33% of
the nurses had completed the competency
prior to the educational campaign. 41%
were unsure if they had completed the
competency or stated they did not know
how to use the method. 41% of the
nurses surveyed stated that they had
access to buffered lidocaine. 25% of the
nurses stated that they preferred to start
IVs using the buffered lidocaine method.
58% answered that the use of Lidocaine
prior to starting an IV would minimize
patient discomfort during the
introduction of an intravenous cannula.
33% answered that the use of lidocaine
makes IV starts more difficult, 37%
believed it obscures the vein, 40%
thought two site infiltrations would cause
more pain and 44% thought it is more
likely to cause an infection at the site due
to two punctures.
The results of the post-survey indicated
that 66% of nurses are aware that using
intradermal infiltration of lidocaine prior
to starting an IV is a standardized nursing
procedure. 83% of the nurses surveyed
had completed the competency since the
educational campaign. 16% were unsure
if they had completed the competency or
stated they did not know how to use the
method. 19% of the nurses surveyed
stated that they had access to buffered
lidocaine. 19% of the nurses stated that
they preferred to start IVs using the
buffered lidocaine method. 63%
answered that the use of Lidocaine prior
to starting an IVs would minimize patient
discomfort during the introduction of an
intravenous cannula. 47% answered that
the use of lidocaine makes IV starts more
difficult, 47% believed it obscures the
vein, 52% thought two site infiltrations
would cause more pain and 35% thought
it is more likely to cause an infection at
the site due to two punctures.
EVALUATION: This study found
numerous positive results as well as some
surprising results. Awareness of the
standardized nursing procedure increased
by 44% as a result of the educational
campaign about the policy and procedure
and there was a 50% increase in the
competency completion. However, 16%
of the surveyed nurses were still uncertain
if they had completed the competency
which raised some concern since
approximately 400 nurses were trained on
this particular IV start method.
Surprisingly, there was a huge decrease in
awareness about access to buffered
lidocaine despite the buffered lidocaine
was put on most units in the hospital.
The placement of the lidocaine on the
units was reinforced during the education
sessions. Despite its accessibility, there was
22% decrease in awareness about
buffered lidocaine access. There was also
a 6% decrease in nurses’ preference about
starting IVs with the use of lidocaine.
There was only a 5% increase in nurse’s
perception that this method would
minimize patient discomfort during the
introduction of an intravenous cannula.
There was a 14% increase in discernment
that the use of lidocaine makes IV starts
more difficult, 10% increased belief that
it obscures the vein and 12% increase in
the perception that two site infiltrations
would cause more pain. There was a 9%
decrease in belief that two punctures
would cause an infection at the site of IV
insertion despite nurses’ concern that any
unnecessary puncture of the skin would
put the patient at higher risk for infection,
especially at the IV insertion site.
9
CONCLUSION: Despite current
literature, an internal survey and an
intentional educational campaign to
increase the use of buffered lidocaine to
reduce patient’s pain during IV starts,
nursing perceptions and practice could
not be changed. The policy and
procedure was not mandatory and nurses
were only expected to offer lidocaine to
patients if they perceived it as a benefit
for that particular patient. Further
research should be done on this topic and
the possibility of making the practice
mandatory for all IV starts without
contraindication could ultimately change
practice.
REFERENCES:
Brown, J. (2002). Registered nurses' choices
regarding the use of intradermal lidocaine for
intravenous insertions: the challenge of changing practice. Pain Management Nursing, 3(2),
71-76.
Brown, J. (2003). Using lidocaine for peripheral IV insertions: patients' preferences and
pain experiences. MEDSURG Nursing, 12(2),
95-101.
McNaughton, C., Zhou, C., Robert, L., Storrow, A., & Kennedy, R. (2009). A randomized,
crossover comparison of injected buffered
lidocaine, lidocaine cream, and no analgesia
for peripheral intravenous cannula insertion.
Annals of Emergency Medicine, 54(2), 214220.
VALLEYCARE NURSE MAGAZINE SPRING 2011
Maternal Child
Patient Safety Program
Shelley Barnhill, RN-C, BSN, MA
and Gina Teeples, RN-C, BSN.
The goal of the Maternal Child Department is to promote patient safety and
quality care. Opportunities to reduce
variation, improve communication and
teamwork and include the patient/family
in their care were identified. Based on
evidence, Maternal Child implemented
the following practices:
copies of the terminology, categories and
pattern notification guidelines were
attached to the EFM in every patient’s
room to use as a reference.
Simulation: Research shows that using
either low or high fidelity combined team
A major focus in perinatal nursing is
training improves team performance and
creating a safe, high reliability
patient outcomes, especially in critical
environment for
situations.
patients. Errors in
Maternal Child
the perinatal setting
schedules
have a double
multidisciplinary
impact as both
and
mother and her
interdepartmental
fetus/neonate are at
drills and low
risk for injury.
fidelity simulation.
Research shows that
Our simulations
having a
include maternal,
comprehensive
neonatal and
patient safety plan
pediatric
obstetrical adverse
emergency
i
events.
scenarios. All
As part of our effort
departments who
to bring evidence to
support patients in
the bedside, the
the Maternal Child
Maternal Child
Department
Department
participate
implemented a
including
Perinatal Safety
physicians, nursing,
Program. The
respiratory
therapy,
Simulation Promotes Highly Reliable Teams
program is based on
laboratory and the
the Institute for
nursing supervisors.
Healthcare
Standardizing electronic fetal
Our format transformed from drills to the
Improvement Perinatal Collaborative
monitoring (EFM): EFM is a major
simulation methodology which includes
model focusing on reducing harm to the
component of the labor and delivery
briefing, scenarios, videotaping and
patient. The three components of the
nurses role and an area of increased
debriefing. During debriefing, areas for
program are: reduce variation;
medical-legal liability. Research shows
improvement are identified by all staff
communication and teamwork and
when labor and delivery nurses and
who participate in the simulation. We
patient/family centered care. Research
obstetricians use standardized
have observed results within the
shows that reducing variation in practice, nomenclature to describe fetal heart rate
department that are consistent with the
improving communication and teamwork (FHR) patterns as well as using specific
literature; including quantitative
and including the patient and family in
categories for pattern identification,
improvements in response time and
care planning and decisions improves
variation is reduced and communication
qualitative improvements surrounding
maternal - neonatal safety as well as
is enhanced, thereby improving patient
comfort and individual performance.
patient satisfaction.
safety. The Department of OB/GYN
Our ongoing plan includes a minimum of
approved use of the National Institute of
annual participation by all staff in
!
Child Heath and Human Development
!!"#$%&#!
scheduled, ongoing simulations.
(NICHD) definitions and guidelines for
!!!'()*(+*,-!
Team STEPPS: The need for team
FHR interpretation as well as creating
"#$%&#!
3(+*#-+4!
.,//%-*&(+*,-!
FHR
Pattern
Notification
Guidelines.
training was identified in our drills and
!8()/!
5(/*67!
!!!!!!!!(-$!
simulation as an opportunity for
All labor and delivery nurses received
.#-+#)#$!
!!!!!0#(/1,)2!
.()#!
improvement, especially in the areas of
mandatory education on the
changes in terminology and FHR role delineation and communication.
!!!!!!!!!!!!!!!"#$%&#!'()*!+!,#)-.(/(0!1(2#/3!,)45)(*!
Categories as well as interventions ValleyCare chose the Team STEPPS
"#$%&'($!)*+,!-./'0'1'(!)+*!2(%3'45%*(!-,&*+6(,(.'!7(*0.%'%3!8+33%9+*%'06(:!
model, which was developed by the
and management. Laminated
i
10
Department of Defense Patient Safety
“recommendation” rather than situation. Current evidence shows that early
Program in collaboration with the Agency The nurse uses key phrases such as “I
activation of an ETP can improve patient
for Healthcare Research and Quality
need you to come in now,” “I need you to outcomes and recommends nurse
(AHRQ), as a training program for the
evaluate this patient” etc… Use of the R activation to expedite the process. 8
Maternal Child Department. Team
in R-SBAR promotes the sender and
Results from post partum hemorrhage
STEPPS was chosen as it is evidencereceiver having shared mental model,
simulation drills also showed that earlier
based, comprehensive training with a
followed by SBAR standard format for
activation of the ETP would have resulted
focus of improving quality and safety in
sending recurring information as
faster lab draws, results and blood
healthcare. A
preparation. Based
multidisciplinary team
on the evidence, the
was sent to Seattle,
team re-evaluated
Washington for the
the ETP and a
formal training
practice change was
program in August,
implemented
2010 including three
allowing nurse
nurses, an obstetrician,
activation. Nurse
a respiratory therapist,
activation allows for
a neonatal hospitalist
lab to draw the
and a representative
patient and the
from quality
blood bank to
management. In the
dispense units of
Fall of 2010, staff from
uncrossmatched
all departments who
blood to the unit
care for patients in
without the
Maternal Child
physician being at
received Team STEPPS
the bedside. This
training. Attendees
means that when
included obstetricians,
the physician
Simulations include Maternal, Neonatal and
pediatricians, neonatal
arrives lab results
hospitalists, maternal
will be available
Pediatric Emergency Scenarios
child staff, respiratory
and the cross match
therapists, nursing
process will be
appropriate.
supervisors, laboratory and anesthesia.
initiated thus expediting critical care of
Changes we have implemented include
RN activated Emergency
the patient.
interdisciplinary board report and
Transfusion Protocol (ETP):
Back to the Bedside: Evidence shows
incorporation of Team STEPPS concepts Postpartum hemorrhage (PPH) affects one
that giving and receiving report at the
and techniques in daily practice and
to three percent of pregnancies in the first bedside decreases communication errors
simulations. An initial teamwork survey
24 hours after birth and continues to be a and improves patient safety. Bedside
was completed by all participants prior to leading cause of maternal death
report also increases patient involvement
training and staff will complete the same
worldwide. In January of 2010 The Joint
in their care. Maternal Child has
survey as a post-assessment in
Commission issued a Sentinel Event Alert adopted the theme “Nothing About Me
approximately six months. Results will be titled Preventing Maternal Death and
Without Me,” where staff partner with
evaluated and shared with all team
identified hemorrhage following cesarean their patients. We have implemented a
members.
section as one of the most preventable
report process that includes the off going
causes of maternal morbidity and
R-SBAR: SBAR originated in the
and oncoming nurse going to the bedside.
mortality. In July of 2010 the California
military as a standardized way of
The off going nurse introduces the
Maternal Quality Care Collaborative
communicating which allows a
oncoming nurse, checks IV solutions,
(CMQCC) issued a toolkit titled
standardized method of giving and
lines, pumps and emergency equipment,
Improving Health Care Response to
receiving feedback. ValleyCare adopted
the plan of care is reviewed and goals are
Obstetric Hemorrhage. 8 This toolkit
SBAR several years ago as a universal tool
mutually agreed upon and the patient
for communication. In critical situations, provides hemorrhage guidelines and a
white boards are updated.
compendium of best practices
especially on night shift when care
Surgical Pause: Unintended retention
providers are woken up, it is important to hemorrhage management. Based on new
of a foreign body is among the top ten
evidence,
a
multidisciplinary
group
of
quickly get the physician’s attention using
Sentinel Events reported to TJC and
nurses,
lab
and
obstetricians
met
to
key words or attention grabbing phrases.
retained surgical items (RSI) continues to
review
our
current
practice.
In
the
Maternal Child implemented the Rbe a difficult problem to eradicate.
existing
ETP
an
order
from
a
physician
SBAR. R-SBAR starts with
Incorrect counts and RSI occurs due to
must be obtained to activate the ETP.
11
distractions in the operating room. Due
to the nature of maternal child nursing
distractions are increased in the perinatal
operating room. Maternal Child
identified an opportunity to improve
procedures in the perinatal operating
room to decrease distractions, reduce
barriers and have zero RSI. Surgical
counts are the time when it is determined
that there are no RSI. In the past the
scrub tech and circulating nurse
completed the count together and
reported “count correct” to the surgeon.
However, according to the California
Hospital Patient Safety Organization, “…
retained surgical item cases are not the
result of individual negligence but reflects
system problems in the OR…” Evidence
shows that counting should not be passive,
rather it should be interactive. In an
effort to eliminate RSI, Maternal Child
adopted a surgical pause, (referred to in
the literature as “Pause for the Gauze”).
At a designated time in the procedure the
surgical pause occurs. It is a time where
the surgeons stop what they are doing and
actively participate in a count with the
scrub tech and circulating RN, visually
and audibly agreeing that the count is
correct. We are continuing to audit the
surgical pause during cesarean sections
and while we have decreased some
distractions we continue to make
modifications, as needed, to this process.
Staff and physicians are more aware of
the importance of the surgical pause and
the count process has changed from
passive to active.
Patient safety is an ongoing process that
requires constant review of current
evidence and evaluating practice. Our
Patient Safety Program continues to
evolve. Using evidence-based practice we
can make changes that improve patient
safety and patient outcomes. Other areas
we are working on include continuing
education including a Journal Club that
meets monthly, monthly evidence-based
nursing education modules, implementing
interdisciplinary monthly FHR reviews,
expanding standardization in post partum
hemorrhage management and the list
goes on! Additionally we have a very
active Mother Baby Council that has
many projects in the works.
REFERENCES:
Pettker, C.M., Thung, S.F. et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. American Journal of Obstetrics &
Gynecology May 2009.
IHI Improving Perinatal Care Collaborative. Accessed online on 4/29/11 at
http://www.ihi.org/IHI/Topics/PerinatalCare/Peri
natalCareGeneral/PerinatalCareGeneralHomePage
.htm
American College of Obstetrics and Gynecologists
(ACOG). Practice Bulletin: Intrapartum fetal heart
rate monitoring; nomenclature, interpretation and
general management principles. No. 106. July,
2009.
Erin DNP
Bonnell, Kristine BSN
Brown, Michelle BSN
Chau, Angelina DNP
Chen, Stephanie MSN/MBA
Daco, Angelina BSN
Degoey, Christine BSN
Fisher, Juliette BSN
Fortes, Kristina MSN/FNP
Kiely, Cathy MSN
Machado, Kimberly MSN/
FNP
Agency for Healthcare Research and Quality:
TeamSTEPPS; Strategies & tools
to enhance performance and patient safety training
manual.
Lyndon, A & Lagrew, D. et al. (Eds). Improving
Health Care Response to Obstetric Hemorrhage.
(California Maternal Quality Care Collaborative
Toolkit to Transform Maternity Care). Developed
under contract #08-85012 with the California Department of Public Health; Maternal, Child and
Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, July
2010.
The Joint Commission Sentinel Event Alert: Preventing Maternal Death. Issue 44, January 26,
2010.
Baker, S.J. Bedside shift report improves patient
safety and nurse accountability.
Journal of Emergency Nursing. 2010; 36: 355-358.
Association of periOperative Nurses. Perioperative
Standards and Recommended Practices. (2010).
Gibbs, V.C. A goal for all California hospitals: zoom
in on zero retained surgical items. California Hospital Patient Safety Organization; Patient Safety News
Dec, 2010 Vol 2 Nbr 12
Gibbs, V.C. NoThing Left Behind. Feb. 7, 2010 at
www.nothingleftbehind.org accessed on Jan. 20,
2011.
Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN). Practice Bulletin: Fetal
Heart Monitoring. November, 2008.
National Certification Corp. (NCC) Monograph.
NICHD Definitions and Classifications: Application
to Electronic Fetal Monitoring Interpretation. Vol.3,
No 2, 2010.
Nurses Pursuing Higher Education
Bashaw,
Kuehster, C.R. & Hall, C.D. Simulation: learning
from mistakes while building communication and
teamwork. Journal for Nurses in Staff Development
Vol 26, Nbr 3, 123-127, May/June 2010.
Maier, Christiane MSN/APN
Marshall, Tricia BSN
Martin, Lisa BSN
McCorkle, Jeanne BSN
Ngugi, Mary MSN
Padda, Seema BSN
Rillston, Jennifer BSN
Turner, Laureen MSN
Warren, Glenda BSN
Wheeler, Gina BSN
Williams, Gina BSN
12
2010 - 2011 Graduates
Bowers, Lani BSN
Edwards, Brian MSN/FNP
Forschen, Kiun MSN
Kennedy, Amanda BSN
Shurko, Carole BSN
Stewart, Laura BSN
Yee, Karen BSN
VALLEYCARE NURSE MAGAZINE SPRING 2011
Red Sash for Safety:
A Review of
Observational Research
Findings
Practice class, the nurse developed a
PICO question and a study design.
(PICO is a mnemonic used to describe
the four elements of a good clinical
foreground question. P--Patient, IIntervention, C-Comparison,O-Outcome.
Jeanette Kitt BSN, RN, CCRN
The Institute of Medicine (IOM) in
their 2007 report, Preventing
Medication Errors, reported an
estimated 1.5 million people are
injured by medication errors every
year (IOM, 2007). The estimated
cost of these errors is estimated at
billions of dollars. One method for
reducing medication errors is by
decreasing interruptions of nurses
during medication preparation and
administration.
Some of the methods found in
the literature used to decrease
interruptions during medication
administration are described
below. (Anthony, Wiencek,
Bauer, Daly, & Anthony 2010;
Pape, 2008; Richards, 2008)
Signs: Signs used in the
Nursing unit or in proximity to
the medication preparation area to
request staff members or visitors to
maintain a quiet environment and avoid
interruptions during medication
administration.
Vests: Vests worn by nurses during
medication administration provide a
visual cue to other staff or visitors to
avoid interruptions during medication
administration. Nurses in Kaiser South
San Francisco documented at 47%
decrease in medication errors over five
months of vest use during medication
administration.
Leadership: Nurse leaders rounding on
units to demonstrate support for the new
interruption reduction process.
Observational audits: audits by charge
nurses, managers or other auditors
provide data on actual (not reported)
behavior during medication preparation
and administration.
No interruption zones: Red duct tape
around all areas where medication are
prepared such as medication carts or
medication dispensing device in critical
care units.
The nurse conducting the observational
study attended the Evidence-Based
Practice class presented by the University
of California at San Francisco . Using the
information from the Evidence-Based
A baseline survey was conducted over 5
non-consecutive dates in June and July of
2010. For consistency, nineteen
medication passes were observed by a
single observer during the 0900
medication passes. It was note there were
69 interruptions during the 19 observed
medication passes.
The original plan was for the nurses to
wear brightly colored vests. This was
reviewed at the Nurse Practice Council
and the direct care nurses stated they
would prefer to wear colored sashes. The
nurses requested sash material that could
be wiped with approved cleaning agents.
Another consideration was avoiding any
latex material. The Materials Liaison RN
searched for a material for the sashes.
Finally, the Nurse Practice Council
approved a red, non-latex, stretch band
used by physical therapy for exercises.
Cost for a roll of red sash material was
$44.19 for 25 yards. An average of 5 feet
(approximately 1.67 yards) was needed for
one red sash. One roll would produce
approximately 15 sashes at a cost of $2.95
each. The red sashes were kept in a bin
near the medication cart. Nurses were
instructed to use the sashes and clean
them after their shift or if visibly soiled. In
isolation rooms, the sashes were worn
under a water proof isolation gown.
13
Research Question:
Will interruptions of nurses during
medication preparation and
administration decrease if the nurse is
wearing a brightly colored sash? (See
photo of nurse wearing red sash)
RESULTS:
Following education and posters
describing the purpose of the red
sashes on one nursing unit the
change was implemented. The
nurses were noted to wear the
red sashes about 90% of the
time at the beginning with a
decrease to about 40% of the
time when the second evaluation
in September was completed.
The same nurse conducted 18
observations of 0900 med passes
over 5 days. During the second
observation in September, a total
of 55 interruptions were
observed of all nurses wearing
and not wearing sashes.
The nurses wearing the red
sashes were interrupted 22 times
compared to the 33 times for
nurses without red sashes. The
nurses wearing red sashes were
interrupted less frequently than those not
wearing the sashes.
EVALUATION:
Interruptions to medication
administration were noted to decrease in
the nurses who wore red sashes.
Compliance with wearing the sashes was
identified as problematic. A decrease in
the use of sashes from (90 to 40%) was
observed during the course of the two
month trial. The nurses were interviewed
following the observations to understand
the nurses’ perceptions of wearing or not
wearing the sashes. Some of the reasons
nurses gave for not wanting to wear sashes
was a perceived increase in interruptions;
nurses stated other care providers
questioned why they were wearing red
sashes. The nurses reported they did not
like putting on and taking off the red
sashes but did not offer acceptable
alternatives (such as vests or no
interruptions zones). Nurses expressed
concerns whether the sashes could be
cleaned effectively between nurses. Nurses
also reported they would be more likely to
wear their own sashes rather than sharing
them with other nurses. Nurses also
voiced concerns about wearing sashes into
isolations rooms even under an isolation
gown.
CONCLUSION:
Interruptions during medication
administration are a well-documented risk
to patient safety. Changing processes to
decrease interruptions during medication
administration have been successfully
implemented at other facilities. The
Nurse Practice Council at ValleyCare
provided a sash that was cost effective and
easily cleaned. Although a decrease in
interruptions to medication
administration was observed a majority of
the nurses were not willing to continue
wearing the red sashes. Some limitations
of the study included the small sample
size (n=18). The trial was conducted on
one unit over a two month period. Only
one unit received education on the
change so nurses who floated onto the
unit or other healthcare providers
interrupted nurses asking about the
sashes. In future trials, the education will
be hospital-wide even if only one
department participates in the change. A
bar-coded medication administration is in
the implementation process and further
studies of interruptions to this system will
be explored for the next project.
References:
Anthony, K, Wiencek, C., Bauer, C., Daly, B., &
Anthony, M. K. (2010). No interruptions please:
Impact of a no interruption zone on medication
safety in intensive care units. CriticalCareNurse
30(3).
Pape, T. (2008) Checklists with medication vest or
sash reduce distractions during medication administration. Agency for Healthcare Research and Quality, Innovations Exchange. Retrieved from
http://www.innovations.ahrq.gov/content.aspx?id=
1799
Institute of Medicine. (2007). Preventing medication
errors. The National Academies Press: Washington,
DC.
Pape TM. (2003). Applying airline safety practices to
medication administration. Medsurg Nurs.
Apr;12(2), pp. 77-93.
Richards, B. (2008). Kaiser South San Francisco
Safe Medication Administration Process (SMAP).
PowerPoint Presentation at the Beacon Collaborative.
RRT (Rapid Response
Teams): Success
Barbara Murphy BSN, RN
In March of 2006, Valley Care responded
to an IHI challenge to take part in “a
campaign to make
health care safer and
more effective” by
establishing our facility’s
first Rapid Response
Team (RRT).
Per IHI specifications,
ValleyCare brought
together “a team of
clinicians who (would)
bring critical care
expertise to the patient
bedside (or wherever
needed)”. ValleyCare’s
Rapid Response Team
consists of a Critical
Care RN and
Respiratory Therapist.
The role of the Rapid
Response Team is to
assess, stabilize, assist
with communication,
educate and support
(staff), and assist with
the transfer of patients
to a higher level of care
if necessary.
Note – results are calculated from 2008-2010 data – in mid-2007 a
consistent means of reporting all Code Blue and RRT calls was
According to the IHI,
“people die
unnecessarily every
single day in hospitals.”
The goal of the RRT is
to “respond to a spark
before it becomes a
forest fire.” Studies have shown that from
66%-70% of patients exhibit signs and
symptoms of physiological instability
within 6 to 8 hours of arrest. Early
response and intervention is a key
component to preventing patients from
requiring full resuscitation. The RRT can
also help reduce the need for transfer to
the ICU by providing immediate
evaluation and intervention to prevent a
patient from further deterioration.
Since implementation of Valley Care’s
Rapid Response Team, our facility has
seen a 50% reduction in the number of
Code Blue calls outside of the ICU (refer
14
to Chart A). With an increase in the
number of RRT calls, we are seeing a
decrease in the number of Code Blue
calls outside of the ICU (refer to Chart
B). This is exactly what we set out to
accomplish in 2006.
Congratulations on a job
well done!
Reference:
http://www.ihi.org/IHI/Programs/Cam
paign
Fusion of Magnetism and
Just Culture
Erin Bashaw MSN, RN, CNE Exploration of
the association between Magnet Recognition
and “Just Culture” is timely and uniquely
aligned to produce a global
healthcare culture shift that is
focused on creating the safest
healthcare through improvements in disclosure, transparency, and public reporting. The
clinical relevance of this investigation illuminates the essential
transformation of the healthcare
systems towards excellence in
nursing and exceptional patient
outcomes by achieving Magnet
Recognition and adopting a
“Just Culture” to ensure a culture of safety.
Magnet History
designation is not a new
phenomenon. Magnet
designation began more
than 25 years ago and has
progressed to become the
apex of achievement for
nursing professionals and
healthcare organizations. A
task force was formed by the
American Nurses
Credentialing Center in
1981 to identify hospitals
that had excellent patient
outcomes, patient
satisfaction, staff
satisfaction, and nursing
retention (ANCC, 2009).
The task force identified 14
components of practice that
created success for these
particular organizations during a very
volatile time in nursing history. The
Magnet Recognition Program designated
hospitals as “Magnet facilities” in the
1990’s. Nearly a decade later, long termfacilities and international organizations
were invited to apply for Magnet
designation. The Magnet Recognition
Program is based on quality indicators
and standards of nursing practice as
defined in the newly revised 3rd edition
(released in 2009) of the ANA Nursing
Administration: Scope & Standards of
Practice (American Nurses Credentialing
Center,2009). In 2002, the program was
officially named The Magnet Recognition
Program; the standard for excellence in
the industry. Healthcare organizations,
hospitals, and nurses look to Magnet
designated facilities for answers to
achieving excellence in both nursing
practice and practice standards (Wolf,
Triolo & Ponte, 2008). Significance of
Magnet
Achieving magnet designation means that
an organization has created an
infrastructure of interdisciplinary care
that successfully integrates best practice,
promotes the highest quality care, and
produces unprecedented patient care
outcomes, while promoting collaboration
and shared-decision making (Armstrong
& Laschinger, 2006). Magnet hospitals
report higher levels of nurse satisfaction,
patient satisfaction, improved quality of
care, reduced errors, reduced falls,
reduced number of hospital acquired
pressure ulcers, and lower mortality rates
(Drenkard, 2010). Magnet hospitals
report better patient outcomes than nonmagnet hospitals (Armstrong &
Laschinger, 2006) and also tend to rank in
the top 10 % for excellence throughout
15
the nation (Drenkard, 2010). Additionally,
nurses in Magnet designated facilities
report that they are “more likely” to
report errors and participate in error –
related problem solving because they felt
empowered by the culture of the
organization and had supportive
relationships with senior
administration (Hughes, Chang &
Mark, 2009). Magnet designation
also has fiscal implications for
healthcare organizations.
Reducing length of stay,
facilitating exceptional patient
outcomes, higher patient and staff
satisfaction levels, reducing
occupational injury, lowering
nursing turnover rates, and
recruiting of outstanding
experienced nurses translates into
lower overall operational costs
(Poduska, 2005).
Understanding “Just Culture”
“Just Culture” is a relatively new
model for the healthcare industry,
but is not a new concept. The
theory of “Just Culture” was
originated by James Reason in
response to horrifically
devastating events that occurred
in three industries riddled with
risk: the military, air traffic
control, and nuclear power plants
(Reason, 2000).
Reason describes these
organizations: “high reliability
organizations” and dynamic
organizations that are influenced
by external and internal forces that are
constantly changing, under intense time
constraints, and have relatively few
negative outcomes despite the likelihood
great catastrophe. The theory of “Just
Culture” seeks to mitigate system failures
in organizations, such as healthcare, that
have inherently high levels of risk because
they are operated by human beings who
are known to be fallible. “Just Culture”
promotes organizational learning by
accepting that mistakes will happen,
accountability by identifying behaviors
that inherently expose organizations to
risk, and building resilience by promoting
industry safety.
Organizations that adopt the “Just
Culture” model accept that errors occur
VALLEYCARE NURSE MAGAZINE SPRING 2011
with and without negative outcomes.
Each type of error is equally important to
disclosure by those involved, because the
act of error identification and reporting
builds trust, transparency, quality care,
and patient safety. “Just Culture”
embraces system failures, errors, and
weaknesses for the purpose of turning
them into educational opportunities for
improvement and learning (Mayer &
Cronin, 2008).
There are three types of behaviors that
contribute to errors: “Human Error”, “Atrisk Behavior”, and “Reckless behavior.”
Human error happens unintentionally
and without mal-intent. At-risk behavior
consists of acts that are designed to cut
corners and save time, despite the known
but seemingly justified danger. Reckless
behavior consists of acts that disregard all
safety measures (Reason, 2008).
Other industry experts have expanded the
concept of “Just Culture”, such as David
Marx and Lucian Leape. Marx (2001)
argues that each person should be held
accountable for their errors and thorough
examination of the error is essential to
determine the individual’s level of
responsibility. Marx expands the concept
of “Just Culture” to include a fourth
domain of accountability: “knowing
violation”. This action goes far beyond
“reckless behavior”. Those that
participate in this type of behavior
knowingly do as at the risk of patient
safety and have no regard for safety itself
(Marx, 2001). Lucian Leape, founder of
the Lucian Leap Institute, originated by
National Patient Safety Foundation, is
also considered a pioneer in patient safety.
Leape also argues the necessity to identify
individual accountability and
responsibility for patient safety and the
need to develop a systematic response to a
healthcare culture of safety (Leape,
Berwick, Clancy, et al. 2009).
Implementing a “Just Culture” that
includes and expects disclosure and
reporting from all employees creates trust
within a healthcare system. Trust will
help eliminate the barriers to disclosure
that include fear of punitive action by
leadership, retribution from senior
leadership and fellow co-workers,
criminalization of errors (Brous, 2008),
and social isolation from colleagues.
According to one study, 40% of clinicians
were too intimidated to report errors
(Joint Commission, 2008). Non-clinicians
were more likely to report errors than
front-line caregivers (Singer, Gaba,
Geppert, Sinaiko, Howard & Park, 2002).
“Just Culture” is not a non-punitive error
reporting system. It does not negate the
responsibility of the care giver’s
accountability or organizational liability.
Adopters of “Just Culture” recognize that
errors need serious investigation and
critical evaluation of facts (Dekker, 2007).
Counseling, remediation, termination,
and possible criminalization of errors are
not removed from this theory (Hader,
2006). “Just Culture” seeks to promote
organizational commitment to universal
safety in healthcare by increasing
awareness, self-awareness, error reporting
education, performance, and industry
compliance (Scalise, 2006). Additionally,
“Just Culture” looks to prevent errors by
looking forward and anticipating when
and where errors may occur and how
they can be prevented.
Magnet Recognition and “Just
Culture”
The relationship between Magnet
Recognition and “Just Culture” may not
be obvious, but the benefits of the union
are undeniably profound for the
healthcare industry. “Just Culture” unites
employees by creating shared
responsibility in the pursuit of patient
safety, increases quality of care and
awareness, promotes nurse retention
through trust, strengthens morale among
staff pursuing excellence as a team, and
maximizes opportunity of organizational
learning. “Just Culture” transforms every
mistake and every error into an
opportunity to learn for the purpose of
improving patient outcomes across the
entire organization.
Translating “Just Culture” into
Magnet Readiness
Structural Empowerment
Magnet Recognition is granted to
organizations that create an infrastructure
of collaboration among all staff members
and fosters a culture of shared-decision
making. According to one article, nurses
16
reported feeling empowered, more
satisfied with their work, more able to
contribute to the organization as a whole,
and more likely to report problems when
related to quality of care issues
(Armstrong & Laschinger, 2006) in
hospitals that are able to make the “links”
between structural empowerment,
magnet, and culture of safety.
Additionally, nurses who felt supported
and empowered by their managers and
organizations were more likely to stay at
their current place of employment
(Kliensman, 2004).
Exemplary Professional Practice
“Just Culture” has the potential to
increase retention rates for hospitals,
reinvent nurse administrators through a
deeper understanding of transparency,
disclosure, public reporting, and
establishing the foundation for the
transformation of nurse satisfaction. Not
only does it promote personal
development through critical selfevaluation and mastery of awareness, but
will create better opportunities for
achieving magnet status and the quality of
patient care (Wagner, 2007). Magnet
status is highly dependent on an
organization’s ability to retain
experienced nurses (Wagner, 2004).
According to Spetz (2007), turnover
decreases permanent staff satisfaction
because of per diem nursing staff, registry
nursing staff, and traveling nurse usage.
One of the major considerations for
attaining Magnet is the staff nurse
retention rates (Upenieks, 2003). Nurses
who feel compelled to promote safety and
organizational unity are likely to stay at
their current place of employment.
Additionally, morbidity and mortality
rates are lower at Magnet facilities
because they tend to employee nurses
who are more experienced, have higher
levels of education, and have less turnover
of nursing staff (Aiken, Clark, Sloane,
Lake & Cheney, 2008).
Transformational Leadership
Leadership skills and management styles
influence all aspects of nursing care
because of the amount of time nurse
managers and nurse administrators spend
with front-line nurses and their ability to
empower and engage staff. One study
reported that an employee’s opinion of
their nurse manager or supervisor had
greater impact on their intent to stay with
an organization than their satisfaction
with the organization itself (Ribelin,
2003). Another study, conducted in
Australia, reported that the morale of
nurses was greatly influenced by the nurse
administrator and had a huge impact on
retention, turnover, workplace health, and
quality of care and safety issues (Day,
Minichiello & Madision, 2006). Nurse
administrators must have substantial
knowledge of their organization to create
opportunities for change and enhance
programs and processes that create a
culture of shared governance and
commitment (Sokol, 2004).
New Knowledge, Innovations &
Improvements
New knowledge is one of the biggest
benefits of “Just Culture”. Exposing
errors, mistakes, and weaknesses within
the patient care domain and healthcare
systems promotes opportunities for the
entire organization to learn for the
purpose of creating positive patient
outcomes. “Just Culture” cultivates
innovation and improvements by
investigating errors and designing
systematic efforts to prevent future one.
Empirical Outcomes
Empirical outcomes are the supporting
data that hospitals and healthcare system
collect over many years to prove that they
have achieved the required elements of
Magnetism. Success in the
aforementioned areas would provide the
evidence necessary to support Magnet
readiness.
References:
Armstrong, K., & Laschinger, H. (2006).
Structural empowerment, magnet hospital
characteristics, and patient safety culture:
making the link. Journal of Nursing Care
Quality, 21(2), 124-134.
Brous, E. (2008). The criminalization of unintentional error: implications for TAANA.
Journal of Nursing Law, 12(1), 5-12.
Center for Nursing Advocacy. (2008). What is
Magnet status and how's that whole thing
going? Retrieved from
http://www.nursingadvocacy.org/faq/magnet.h
tml.
Curtin, L. (2003). An integrated analysis of
nurse staffing and related variables: effects on
patient outcomes. Online Journal of Issues in
Nursing, 8(3).
Day, G., Minichiello, V., & Madison, J.
(2006). Nursing morale: what does the literature reveal?. Australian Health Review, 30(4),
516-524.
Dekker, S. (2007). Just Culture: Balancing
Safety and Accountability. Burlington, VT:
Ashgate Publishing Company.
Drenkard, K. (2010). The business case for
MAGNET. Journal of Nursing Administration, 40(6), 263-271.
Hader, R. (2006). A just culture proves just
right. Nursing Management, 37(6), 6-6.
Hughes, L., Chang, Y., & Mark, B. (2009).
Quality and strength of patient safety climate
on medical-surgical units. Health Care Management Review, 34(1), 19-28.
Institute of Medicine. (2001). Crossing the
Quality Chasm: A New Health System for the
Twenty-first Century. Washington: National
Academy Press.
The Joint Commission. (2008). Behaviors that
undermine a culture of safety. Retrieved from
http://www.jointcommission.org/assets/1/18/S
EA_40.PDF.
Kliensman, C. (2004). The Relationship between Managerial leadership Behaviors and
Staff Nurse Retention. Hospital Topics: Research and Perspectives on Healthcare, 82(4),
4-10.
Aiken, L., Clarke, S., Sloane, D., Lake, E., &
Cheney, T. (2008). Effects of hospital care
environment on patient mortality and nurse
outcomes. Journal of Nursing Administration,
38(5), 223-229.
Leape, L., Berwick, D., Clancy, C., Conway,
J., Gluck, P., Guest, J., et al. (2009). Transforming healthcare: a safety imperative. Quality & Safety in Health Care, 18(6), 424-428.
doi:10.1136/qshc.2009.036954.
American Association of Colleges of Nursing.
(2010). Creating a More Highly Qualified
Nursing Workforce. Retrieved from
http://www.aacn.nche.edu/media/factsheets/nu
rsingwrkf.htm.
Marx, D. (2001). Patient Safety and the “Just
Culture”: A Primer for Health Care Executives. New York, NY: Columbia University.
American Nurse Credentialing Center. (2009).
Magnet Recognition Program Overview. Retrieved from
http://www.nursecredentialing.org/Magnet/Pro
gramOverview.aspx
Mayer, C., & Cronin, D. (2008). Organizational accountability in a just culture. Urologic
Nursing, 28(6), 427-430.
Poduska, D. (2005). Magnet designation in a
community hospital. Nursing Administration
Quarterly, 29(3), 223-227.
17
Reason, J. (2000). Education and debate. Human error: models and management. BMJ:
British Medical Journal, 320(7237), 768-770.
Reason, J. (2008). The Human Contribution:
Unsafe Acts, Accidents and Heroic Recoveries.
Burlington, VT: Ashgate Publishing Comapany.
Ribelin, P. (2003). Retention reflects leadership style. Nursing Management, 34(8), 18-23.
Scalise, D. (2006).The see-through hospital.
H&HN: Hospitals & Health Networks, 80(11),
34.
Singer, S., Gaba, D., Geppert, J., Sinaiko, A.,
Howard, S., & Park, K. (2003). The culture of
safety: results of an organization-wide survey
in 15 California hospitals. Quality & Safety in
Health Care, 12(2), 112-118.
Sokol, P. (2004). Patient safety. Transforming
the workplace environment: Port Huron Hospital's transformation model. Nursing
Economic$, 22(3), 152-153.
Wagner, C. (2007). Organizational commitment as a predictor variable in nursing turnover research: literature review. Journal of
Advanced Nursing, 60(3), 235-247.
Spetz, J. (2007). Forecast of the Registered
Nurse Workforce in California. Center for
California Health Workforce Studies. University of California, San Francisco.
http://www.rn.ca.gov/pdfs/forms/forecasts200
7.pdf
Upenieks, V. (2003). Recruitment and Retention Strategies: A Magnet Hospital Prevention
Model. Nursing Economics, 21(3), 7-23.
Wagner, C. (2004). Is you nursing staff ready
for magnet hospital status? Journal of Nursing
Administration, 34(10), 463-468.
Wolf, G., Triolo, P., & Ponte, P. (2008, April).
Magnet recognition program: the next generation. Journal of Nursing Administration,
38(4), 200-204.
ValleyCare Health System
Educating on Best Practices,
Throughout the Years
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