TL8EO

 

Advocacy and Influence TL8EO

 

Using the required empirical outcomes (EO) presentation format, provide one example of an improved patient outcome, associated with a Nurse AVP’s/Nurse Director’s or Nurse Manager’s membership in an organization level, decision-making group.

  • Patient outcome data may be presented at the organizational, division, or unit- level.

 

 

Example: Organization-level, Decision-making Task Force Decreases HAPIs Associated with Proning

Problem
The typical population of the Surgical Intensive Care Unit (SICU) consists primarily of patients who have undergone a neurosurgery, CABG, extensive general surgery, or have experienced a trauma. However, the SICU was the primary location for the care of critical COVID patients from March 2020 through March 2022.

 

The care of these patients was challenging in many ways, and the team was continually learning and adjusting in response to new knowledge and recommendations for nursing practice. Pronation was an intervention with the potential to improve patient outcomes. Before the pandemic, the SICU team had little experience with pronation therapy. As most SICU patients had contraindications to proning or would not benefit from it, the team was learning to perform a skill new to them on very fragile patients. The team subsequently observed a disturbing trend of skin breakdown, especially facial injuries, resulting from pronation.

 

Pre-Intervention

The SICU had historically been strongly focused on preventing skin injuries, supplementing the required quarterly National Database of Nursing Quality Indicators (NDNQI) prevalence study with monthly skin surveys to stay on top of any issues. Clinical nurses disturbed by the pattern of skin injuries approached Nurse Manager Trish Nicholas, BSN, RN in September 2021, and all agreed that an organization-level task force was needed to find solutions and better serve patients. These clinical nurses, who became nurse champions, included Melissa Owen, BSN, RN; Jennifer Gray, RN; Logan Jenkins, BSN, RN, CCRN; and Nayoung Murders, RN.

 

In September 2021, the SICU rate of hospital acquired pressure injuries (HAPI) for proned patients was 100.

 

Goal Statement

To improve the SICU HAPI rate for proned patients.

 

Participants

 

 

Critical Care HAPI Reduction Task Force

 

Name/Credentials

Discipline

Title/Role

Department

Trish Nicholas, BSN, RN

Nursing

Nurse Manager/ Chair

SICU

Melissa Owen, BSN,
RN

Nursing

Clinical Nurse

SICU

Jennifer Gray, RN

Nursing

Patient Care Coordinator

SICU

Logan Jenkins, BSN, RN, CCRN

Nursing

Clinical Nurse,
Unit Based Council Chair

SICU

Cathi Gray, RRT

Respiratory

Respiratory
Therapist

Respiratory
Therapy

Catherine Cevela, RRT

Respiratory

Supervisor

Respiratory Therapy

Amy Fentress, MSRDNLD

Nutrition

Dietician

SICU/Medical ICU

Ashley Walker, BSRT,
RRT

Respiratory

Respiratory
Therapist

Respiratory
Therapy

Julie Clift-Hayes, BSRT, RRT

Respiratory

Manager

Respiratory Therapy

Megan Savage, MS, OT/L

Rehabilitation

Manger

Rehab Services

Lyssa Edwards, BSN, RN, WOCN

Nursing

Wound and Ostomy Care RN

Inpatient Diabetes/
Wound

Syed Mustafa, MD

Physician

Critical Care
Director

Critical Care

Nayoung Murders, RN

Nursing

Patient Care Coordinator

SICU

Sheila Clemens, BSN, RN

Nursing

Nurse Manager

Medical ICU

 

Description of the Intervention
October 2021
Nicholas created the organization-level task force and led the first meeting with the clinical nurse champions on October 5, 2021. Nicholas determined the task force needed to be interprofessional to ensure the inclusion of all stakeholders who participate in the care of these patients. The team knew that all stakeholders’ expertise was needed to create a thorough plan and that interprofessional buy-in was crucial to their success. Nicholas consulted with ICU Director Syed Mustafa, MD to include him in the task force for his expert input and to enable the team to obtain approval for any proposed interventions. This would enable them to implement the plan promptly rather than having to approach Mustafa separately and then circle back to the rest of the task force.

 

In the first week of October 2021, the interprofessional, organization-level task force agreed on the following interventions to decrease HAPIs in patients undergoing proning:

  • Changing prone/supine intervals from 16 hours/8 hours to 12 hours/6 hours.
  • Continuing the application of Allevyn protective dressings. Before applying Allevyn to facial areas, Sure Prep is to be applied to the chin, cheeks, upper lip, and forehead for added protection and allowed to dry.
  • Nicholas contacted the Supply Chain manager to increase the par levels of Allevyn and Sure Prep products.
  • Clipping facial hair for better adherence of Sure Prep and to allow better visibility for early detection of skin injury.
  • Continuing to place patients in swimmers’ position, but now alternating arm and head positions every 4 hours.
  • Vent to be placed at the head of the bed to decrease the risk of airway dislodgement during proning and repositioning.
  • Using roll pillows to elevate the patient. This intervention would offer protection to the abdominal, pelvic, and breast areas and avoid hyperextension of the neck from the facial pillow. Nicholas contacted the Supply Chain manager to increase the par levels of these products.
  • Bolus feedings while supine would continue, but trickle feeds would be added as tolerated during proning.
  • Pro Stat supplements would be given three times daily to boost protein.

 

The following information was distributed:

  • Nicholas shared the task force’s meeting minutes with its members. She also brought the task force interventions and information to SICU clinical nurses through handouts and daily huddles.
  • Nicholas approved tip sheets to be posted in the ICU for reference and in the rooms of patients who are being proned.
  • Task force champions provided real-time demonstrations when patients were proned on the unit.
  • Nicholas arranged for the Rehabilitation manager to be available during these demonstrations for her validation of body alignment.

 

The following additional interventions were implemented beginning on October 16, 2021:

  • Nicholas communicated with Mustafa to support making every effort to prone patients on the same schedule. Mustafa approved an abbreviated time for a newly proned patient to sync the schedule in the unit if the patient had been prone for at least eight hours. Syncing schedules enabled the team to better plan for this time-intensive intervention and to coordinate resources effectively and consistently.
  • Task force members were available for consultation as needed, and teams were encouraged to call on specialists (wound care, dieticians, respiratory) for input and recommendations. Nicholas ensured the task force had the specialists’ contact information in case she was unavailable.
  • Central Supply made the necessary adjustments to par levels for Allevyn and foam rolls and added Sure Prep to SICU supplies. This minimized delays related to product availability.
  • The SICU patient care coordinator ensured compliance with Pro Stat through verbal reminders and chart checks. Clinical nurses were empowered to enter these orders with assurance that the order would be supported and signed by the intensivist.

 

References

Bamford, P., Denmade, C., Newmarch, C., Shirley, P., Singer, B., Webb, S., & Whitmore, D.. (2019, November). Wyccn. Guidance For: Prone Positioning in Adult Critical Care. https://www.wyccn.org/uploads/6/5/1/9/65199375/icsficm_proning_guidance_final
_2019.pdf

 

Flynn Makic, M. B. (2020). Prone position of patients with COVID-19 and acute respiratory distress syndrome. Journal of PeriAnesthesia Nursing, 35(4), 437–438. https://doi.org/10.1016/j.jopan.2020.05.008

 

Miller, M. (2017). The secret of teams: What great teams know and do book - everyone. Skillsoft. https://www.skillsoft.com/book/the-secret-of-teams-what-great-teams-know-and-d o-38568080-c553-11e7-9233-92959924aa1c

 

National Pressure Injury Advisory Panel. (2020). Pressure Injury Prevention - PIP Tips for Prone Positioning. https://cdn.ymaws.com/npiap.com/resource/resmgr/press_releases/NPIAP_PIP_ Tips_for_Proning.pdf

 

Nicholas led and supported the organization-level decision-making task force by removing barriers, advocating for resources, and communicating with physicians, task force members, and the SICU clinical nurses. Nicholas’s leadership resulted in a decrease in the SICU HAPI rate for patients undergoing pronation therapy.

 

The interventions were fully implemented by the end of October 2021.

 

Outcome

(Evidence TL8EO-1, SICU HAPI Rate for Proned Patients)