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!!
REFERENCESHarris, J., Roussel, L., (2010). Initiating and sustaining the clinical nurse leader role.
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
baumannii meningitis: report of two cases and literature review. The Journal Of Hospital Infection, 71(2), 176. doi: 10.1016/j.jhin.2008.09.018
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
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