THE CNL ROLE IN CRITICAL

CARE: THE ICU MICROSYSTEM

Ann Deerhake, MS, RN, CNL, CCRN

CNL USF Conference Logo 2011

THE CRITICAL CARE CNL ROLE Contrast the CNL role between critical

care and other areas.

Discuss strategies for the development of a continuous ICU performance improvement plan.

Consider the positive effects the CNL can have on ICU staff empowerment, financial health and patient outcomes.

LOCATION, LOCATION,LOCATION!!

Is the CNL role new to this facility? This setting?

What types of leadership and staff are present in this setting?

What effect will this setting have on the CNL duties and responsibilities?

CLINICIAN ROLE

Perform advanced patient assessments

Plan care/Change care

Empower frontline nurses

Partner with the interdisciplinary team

Grow clinically

CLINICIAN ROLE IN ICU

Perform advanced patient assessments in an intensive care context

Plan care/change care letting inter/intra-disciplinary input guide you

Empower frontline nurses by supporting/ debriefing them within their high stress environment

Partner with the interdisciplinary team by learning from them/anticipating their needs

Grow clinically as a CNL as well as a critical care nurse

ADVOCATE Empower the patient

Assist with continuity of care

Promote evidence-based practice

Build collaborative relationships

Speak up!

ADVOCATE IN ICU Empower the patient

or his/her designated speaker

Assist with continuity of care especially with pulled staff

Promote evidence-based practice by encouraging frontline nurses to think

beyond complacency

Build collaborative relationships with all microsystem members, patients, families

Speak up! Be assertive and confident

TEAM MEMBER/MANAGER/BUILDER Know when to lead, when to follow

Develop personal competencies

Find a common purpose

Identify and resolve barriers

Set your team apart from the rest

TEAM MEMBER/MANAGER/BUILDER IN ICU

Know when to lead, when to follow and how to encourage others to use

their strengths

Develop personal competencies with realistic expectations

Find a common purpose within ownership, not buy-in

Identify and resolve barriersamongst strong personalities

Set your team apart from the rest setting a role model for excellence

SYSTEMS ANALYST/RISK ANTICIPATOR

Identify patient safety issues/risk

Develop realistic action plans

Promote systems thinking

Encourage others to get involved

SYSTEMS ANALYST/RISK ANTICIPATOR IN ICU

Identify patient safety issues/risk focusing on reducing nosocomial infection

Promote systems thinking in addition to advanced critical thinking

Develop realistic action plansutilizing frontline staff knowledge

Encourage others to get involvedas health promotion and safety officers

MEMBER OF A PROFESSION Encourage horizontal leadership

Meet personal CNL goals

Help other nurses reach their goals

Elevate the profession of nursing

MEMBER OF A PROFESSION IN ICU

Meet personal CNL goalswithin the context of critical care

Help other nurses reach their goalsto become facility leaders

and professional nurses as well as excellent caregivers

Elevate the profession of nursingand critical care nursing

NEVER FORGET…

ATTITUDE REFLECTS LEADERSHIP

EDUCATOR Share what you know “knowledge

transfer”

Be a coach

Research and disseminate

Formally present

EDUCATOR IN ICU Share what you know “knowledge

transfer” it goes both ways!

Be a coach and an issue resolverin critical situations

Research and disseminate information on the fly and methodically

planned

Formally presentas an ICU nurse and educator

OUTCOMES/ INFORMATION MANAGER Improve communication

Reduce errors

Increase patient/family satisfaction

Increase recruitment/retention

Disseminate information using variety of methods

OUTCOMES/ INFORMATION MANAGER IN ICU

Improve communication between a large, multidisciplinary team

Reduce errors within a high acuity environment

Increase patient/family satisfactionwithin an incredibly stressful environment

Increase recruitment/retention of nurses with increased responsibility with minimal compensation

Disseminate information using variety of methodsand electronic technologies

PUTTING IT ALL TOGETHER: PERFORMANCE IMPROVEMENT Performance improvement requires

all the pieces to make a whole Assess the ICU microsystem utilizing

the five P framework. Further analyze the ICU microsystem

identifying problemsreviewing peer literature developing an action plan.

PREVENTION OF NOSOCOMIAL

VENTRICULITISIN THE ICU

THE SRMC ICU MICROSYSTEM

Purpose Mission Statement--To provide quality,

compassionate care to all critically ill patients and their families; to exemplify the core values of excellence, human dignity, justice, sacredness of life and service.

People/Patients Common DRGs include sepsis, respiratory and

renal failure, GI bleeding, trauma/ traumatic brain injury, post-op brain surgery

Focusing on those that require an external ventricular drain, i.e. hemorrhagic CVA, closed head injury, post-tumor resection

THE SRMC ICU MICROSYSTEM

Professionals (within the microsystem) Unit manager/ Care facilitator Intensivist/Attending physicians Nurses Respiratory Care partners/Respiratory Therapy Nursing assistants/Unit Clerks

Professionals (within the mesosystem) Physicians Neuroscience Clinician Social workers/Case managers Dedicated ancillary Staff, e.g. satellite

pharmacy, dieticians, housekeepers

THE SRMC ICU MICROSYSTEM

Processes External Ventricular Drain (EVD) insertion

and maintenance Patient requiring EVD admitted to SRMC EVD inserted per MD in ICU or Surgery Daily care per frontline RN Daily CT scans (or as ordered) to monitor

progress Neuroscience Clinician monitors patient

progress Device surveillance per Case Manager MD orders/does not order specific care of EVD Care of EVD determined by primary RNs

EXTERNAL VENTRICULAR DRAIN

THE SRMC ICU MICROSYSTEM

Patterns Risk of EVD infection No protocol for dressing changes

PROBLEM (THE SIXTH P!)

FROM JULY 2008-JULY 2009 20% INCREASE IN EVD

INFECTIONS!(NOSOCOMIAL

VENTRICULITIS)

PEERS (THE SEVENTH P!) Minimal literature exists about EVD care Most studies discuss insertion techniques

along with maintenance care Many studies discuss ICU nosocomial

infection as a whole EVD infection is considered a significant risk Aseptic technique is considered integral in

the prevention of EVD infection Use of distal port for sampling

recommended Routine revision not recommended Most studies say number of EVDs per

patient more predictive of infection than duration of each

PLAN (THE EIGHTH P!) Research Question:

Would initiating a standardized protocol for EVD dressing changes in the SRMC ICU decrease incidence of nosocomial ventriculitis?

Apply to IRB for EVD study approval Develop and initiate a standardized protocol

for EVD dressing changes Notify neurosurgeons of study content and

proposed dressing change protocol Collect EVD retrospective data from the

previous 12 months Collect EVD data for the upcoming 12 months Evaluate compliance with EVD protocol Compare infection rates between groups

STUDY METHODS Developed a simple EVD dressing change

protocol utilizing non-charge items ICU currently stocks: gloves, betadine swabs, drain sponges and tape as needed

Notified physicians via letter regarding proposed dressing change protocol and obtain signed approval from each

Educated ICU nurses, distributed orange folders and laminated protocol cards throughout ICU

Collected retrospective non-intervention data and prospective intervention data

Perform daily EVD/ICP Dressing care· Aseptic technique, wash hands· Wear mask and non-sterile gloves· Remove old dressing carefully· Assess insertion site for drainage, redness or edema· Change gloves · Cleanse with povidine iodine swabsticks x 2, using concentric circles · Allow to dry for 1 minute· Place 4x4 drain sponges x 2 around EVD/ICP· Secure with tape only if needed to maintain placement Monitoring and Documentation· Monitor for: Signs of increased ICP Dislodgement of EVD/ICP I Increased drainage at site· Document on the critical care flow sheet: Supplies used EVD/ICP insertion site assessment Aseptic technique used Patient tolerance Call Ann Deerhake 419-303-7797 or Shar Dunlap 419-236-7237 for assistance. Thanks for your help with this study!! We appreciate all you do!!

EVD/ICP Dressing Change Study Protocol

Verify that patient is eligible· Has an EVD/ICP in place· Older than age 18· Not a prisoner

 Sign consent and leave in orange folder· Sign per patient or authorized representative· If cannot read, read to patient/ representative· If cannot speak English, use interpreter; if cannot secure interpreter services, exclude from study Pre-dressing change preparation· Check Dr. orders for alternative dressing orders· Educate patient/family of need for asepsis during dressing change· Assess need for sedation and/or additional nursing assistance· Confirm patient with two patient identifiers

STUDY DESIGN Controlled trial without randomization Retrospective data vs prospective data 3 designated data collectors: primary

investigator, Neuro CNS and ICU Unit Manager

Blinded to all but primary investigatorSTUDY LIMITATIONS

Small participant number (n=26) Single facility study

STUDY RESULTS ... POSITIVE OUTCOMES

No further CSF infections after daily dressing change instituted (July 2009-July 2010)

Reduced rate of nosocomial ventriculitis from 54% to 0%

Equates to a savings of $44,972

Potentially decreased LOS by 127 days

Increased patient, family and nurse satisfaction

OTHER CNL INFLUENCED POSITIVE OUTCOMES

Reduction of other nosocomial infections savings of $77,095

Reduction of device-related pressure ulcers

90% of ICU, Clinical Nurse 3 or 4

Healthier work environment t/o critical care, increased retention

Collaborative competency Multiple system changes resulting in better patient

care and utilization of nursing resources

THANKS!!

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Sudbury, MA. Jones and Bartlett Publishers LLC.

Korinek, A., Reina, M., Boch, A., Rivera, A., De Bels, D., & Puybasset, L., (2005). Prevention of external ventricular drain—related ventriculitis. Acta Neurochirurgica, 147(1), 39.doi:10.1007/s00701-004-0416-z

Krol, V., Hamid, N., & Cunha, B., (2009). Neurosurgically related nosocomial acinetobacter

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Lackner, P., Beer, R., Broessner, G., Helbok, R., Galiano, K., Pleifer, C. et al., (2008).

Efficacy of Silver Nanoparticles-Impregnated External Ventricular Drain Catheters in Patients with Acute Occlusive Hydrocephalus. Neurocritical Care, 8(3), 360 - 365.doi: 10.1007/s12028-008-9071-1

Lo, C., Spelman, D., Bailey, M., Cooper, D., Rosenfeld,J., & Brecknell, J., (2007). External

ventricular drain infections are independent of drain duration: an argument against elective revision. Journal Of Neurosurgery, 106(3), 378. Retrieved May 20, 2009 from MEDLINE with Full Text.

Monaghan, H., Swihart, D., (2010). Clinical nurse leader: transforming practice, transforming care. Sarasota, FL. Visioninf=g Healthcare Inc.

Orsi, G., Scorzolini, L., Franchi, C., Mondillo, V., Rosa, G.,& Venditti, M., (2006). Hospital-acquired infection surveillance in a neurosurgical intensive care unit. The Journal Of Hospital Infection, 64(1), 23. doi: 10.1016/j.jhin.2006.02.022