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ICU CAUTI Incidence Reduction
Michelle Gamble
Situation:
Catheter-Associated Urinary Tract Infection (CAUTI) rates in the adult Intensive Care Unit (ICU) increased from nine infections in FY21 to 18 in FY22.
Backgroud:
CAUTIs are the most reported healthcare acquired infection. It is important for healthcare providers to understand the complications and effects of CAUTIs. CAUTIs contribute to extended length of stay, increased healthcare costs, and patient morbidity and mortality.
Most CAUTIs are directly related to inadequate urinary catheter care. Evidence based practice demonstrates a decrease in CAUTIs related to the use of Theraworx® Protect wipes twice daily (BID) and as needed (PRN) for patients with a urinary catheter.
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Safe Intra-Hospital Transport of Adult Patients on Non-Critical care Units
Teresa Jahn, Janelle Maciej, and Greta Titus
Plan:
Between 2021 and 2022, two non-critical adult patients returning from the imaging department after an invasive procedure developed increased oxygen needs, which ended in death for on patient and a transfer to critical care for the other.
No formal guidelines exist for the intra-hospital transport by unlicensed personnel may be absent. An intra-hospital transport checklist was developed for non-critical care patients leaving the unit for procedures in the imaging department.
Do:
- A "RN Pre-Invasive Procedure Transport Safety Checklist" was created by a telemetry RN (MSN student, Greta Titus) and CNS, Teresa Jahn
- The checklist was designed to answer questions to determine a patient's hemodynamic and respiratory stability prior to transport by an unlicensed person
- The checklist is to be completed prior to transport on all patients leaving the unit for a procedure in the imaging department (i.e. paracentesis, thoracentesis, biopsy, etc.)
- If one of the questions answered is "yes", the next step is to prompt a huddle with Resource RN or Charge RN to identify f a patient is safe for transport without a RN.
- The "why" for the change was presented by Greta Titus during the November 2022 CentraCare Heart and Vascular Center Clinical (CCHVC) Practice meeting
- Staff were also notified of this change during Telemetry daily huddles and weekly updates
- The trial started on Telemetry beginning 11/1/2022
- Follow up on the progress of the practice change was presented by CCHVC CNS during Telemetry Education Days in January-February 2023
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Clinical Nurse Specialists: A Rare Breed
Teresa Jahn, Evalyn Michira, and Elizabeth Plante
What is a CNS?:
- A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) with graduate level education in nursing.
- CNSs are prepared to provided leadership, consultation, and clinical expertise for patients and their families, nurses, and systems.
- Have the autonomy to diagnose and treat based on advanced clinical assessment like other APRNs (Nurse practitioners, certified nurse midwives, certified registered nurse anesthetists).
- CNS work in all areas of healthcare like clinics, emergency departments, hospital units, entire healthcare systems, or even as independent practitioners/contractors.
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Recognition of Nonconclusive Seizures in Patients After Cardiac Arrest Using
Teresa Jahn and Elizabeth Plante
Background:
Evidence - Prevalence of nonconvulsive status epilepticus or other epileptiform activity in patients who are comatose after a cardiac arrest is between 12-22%. Consistent with the literature, at this facility approximately 12% were found to have non convulsive seizures. Prolonged epileptiform discharges may cause secondary brain injury and increased mortality. In 2020, the American Heart Association recommended EEG monitoring should be promptly performed and interpreted for the diagnosis of seizures in all comatose patients following cardiac arrest.
Local Problem - Comatose patients admitted to critical care after cardiac arrest who require targeted temperature management (TTM) have continuous EEG monitoring ordered STAT. Neurodiagnostic technologists who apply EEG monitoring are not available 24/7.
Conclusions/Implications:
- While the rapid EEG recording may have limitations compared to continuous recordings for diagnostic purposes, it has immediate feedback for monitoring of nonconvulsive status epilepticus.
- Continuous EEG monitoring can take 45 minutes to set up and much longer to obtain diagnosis of status epilepticus.
- Continuous EEGs have broader diagnostic capabilities, however, are not monitored continuously by neurology providers, which could delay the identification of seizure activity.
Recommendations:
- Continue immediate placement of rapid EEG if technologists are not available within one hour.
- Continue to replace rapid EEG with continuous EEG when technologist becomes available.
- Explore improved capabilities for more timely reading and diagnosis of continuous EEG.
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Sterile Tubing Changes to Prevent CLABSIs in the NICU
Rachel Janson and Megan Meyer
Purpose Statement:
NICU patients have a decreased risk of CLABSI infections when two-person sterile central line changes are implemented into central line maintenance bundles compared to bundles that only use one-person clean line change techniques.
Background:
Neonates admitted to the neonatal care intensive care unit (NICU) often require the placement of central lines for the administration of medications, fluids, parental nutrition, and hemodynamic monitoring. Despite their many advantages, central lines can lead to serious infections, known as cental line associated bloodstream infections (CLABSI). These infections are not related to an infection from another site and develop within forty-eight hours of removal. CLABSIs are a major contributor to morbidity and mortality in the NICU population and are costly to hospital systems. According to Mobley & Bizzarro, infants who develop CLABSIs can cost up to an additional $50,000 and add as many as ten days to their hospital stay when compared to other infants without CLABSIs (2017). An evidence-based approach that has shown to improve patient outcomes and reduce CLABSIs is the use of a bundle, which is utilized upon insertion and during maintenance of the central line. Based on the available research, the most common CLASBI bundle elements include: using maximum standard barrier precautions, using a specific skin preparation & line dressing protocol, daily central line need assessments, a two-person line change technique, specific education and training for staff, and quarterly audits (Payne et al., 2018). The St. Cloud Hospital NICU currently utilizes these practices expect for a two-person line change with sterile technique.
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Transitions to Normal Saline ONLY for CVADs
Megan Lehn and Ann Backes
Purpose Statement:
The purpose of this project is to implement a practice change throughout the system to remove heparin flushes for Central Venous Access Devices (CVADS) pending a successful pilot on Medical Oncology.
Synthesis of Evidence:
- Shama et al (2019) conducted a systematic review and meta-analysis including 886 participants that revealed no clear differences in CVC patency between heparin and NS.
- Klein et al (2018) conducted a pilot study on a 30-patient bone marrow transplant unit, each patient had a new CVC and were divided into two groups. Among 698 catheter-associated events overall incidence of central line issues were similar in both heparin and normal saline group.
- Egnatios & Gloria (2021) studies 37 patients receiving clinical trial infusions, they divided the study into two phases. During heparin phase there were 302 port accesses and four alteplase orders, during the NS study there was 261 accesses and seven alteplases orders. Alteplase was successful every time it was used.
- Zhong et al (2017) performed systematic [sic] review on use of heparin v. flushing protocols. Ten randomized control trials involving 7,785 participants were included in the meta-analysis. No general differences found between heparin v. NS in maintaining patency.
- Goossens et al (2013) oncology patients were randomly selected from 2009-2011. 382 were ultimately selected for normal saline group, and 283 for heparin group. All nurses were trained in proper pulsatile technique before study, it was found intimately heparin was not superior in comparison to NS in maintaining the patency of CVC.
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Promotion of National Certification in Telemetry
Janelle Maciej
Situation:
Goal to bring awareness to telemetry nurses, the specialty certifications they are eligible for, and criteria for eligibility. Currently, six telemetry nurses hold a nationally recognized certification.
Action Plan:
- March 19, 2023 was Certified Nurses Day and was the kickoff for the start of encouragement for telemetry nurses to be certified.
- Each telemetry nurse was delivered a card and lifesaver candy inviting them to consider a nationally recognized certification.
- A certification informational packet promoting CV-BC and PCCN certification was placed at each desk and referenced during huddle for one week.
- Certification preparation books are available upon request.
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From Silos to Collaborative Working Relationships with EMS and ED
Angela Moscho
Opportunity:
To establish a strong, collaborative relationship between St. Cloud Hospital Stroke Center, St. Cloud Hospital Emergency Department and Emergency Medical Services.
Background:
Two separate health care systems with one goal in mind: best stroke care for a community member experiencing stroke-like symptoms.
Current Practice in 2017:
- Code stroke activation with LTKW (last time known well) up to 6 hours.
- Inconsistent pre-notifications and pre-activations by EMS and ED.
- St. Cloud Hospital and Mayo Clinic Ambulance with siloed/individualized protocols for their respective health systems.
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Heated High Flow Oxygen Therapy Management of Respiratory, Swallowing/Dysphagia and Nutrition Needs
Jenelle Overgaard
Problem
- Patients diagnosed with COVID-19 pose challenges for oxygenation. Often requiring heated high flow oxygen therapy (HHFOT) for days to weeks, with literflow commonly over 40 L/min with maximum of 60 L/min.
- There is minimal research on aspiration risk at higher literflow, therefore practice included decreasing liter flow to 20 L/min for oral intake was standard.
- During oral intake, with literflow decreased to 20 L/min, patients' oxygen saturations would quickly trend down.
- Alarms indicating low saturation would create anxiety, cause patients to eat faster potentially increasing risk for aspiration.
Solution
- For adult inpatients meeting criteria, increase maximum literflow allowed during oral intake from to 40 L/min.
- Develop guidelines for:
- oxygen supplementation during oral intake
- how/when to consult Speech Language Pathologist
- inclusion of dietitian earlier in hospitalization
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Pupillometry
Elizabeth Plante and Casey Schmidt
Background:
- Measuring pupillary light reflex is a standard part of neurological assessment.
- Changes in pupil reactivity may indicate unfavorable outcomes, such as increased intracranial pressure and brain herniation.
- Physiologic and pharmacologic agents may affect pupil reactivity.
- In some instances, pupillary light reflex is the only piece of neurologic assessment readily testable.
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Dynamic Bronchoscopy for Excessive Dynamic Airway Collapse
Jennier Salaski and Krista Ophoven
Definition:
Excessive Dynamic Airway Collapse (EDAC) is a respiratory condition characterized by >50%luminal narrowing on expiration.
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SCH ICU Expanding PICS Throughout CentraCare
Jessica A. Tindal
Purpose:
Sharing information about Post Intensive Care Syndrome (PICS) to all in CentraCare. PICS symptoms do not appear until weeks to months after a critical care illness so patients at home may not know what to do with their symptoms.
Future Plans:
- May 2023 - introducing CICU to the PICS process during their Nurse Practice meeting.
- May 2023 - updating the Hospital Medicine Section CNS
- Fall 2023 - meeting with the Ambulatory Work Cabinet group to see if our system of notification is working
- What opportunities do we have with teaching Progressive RNs about PICS and our Diaries?
- How can we reach out to our patient population even more: MyChart messages, community education, etc?
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What I Need: Self Care at the Unit Level
Jessica A. Tindal
Purpose:
Self-care is individualized and best done when awarded on a small scale.
Goals:
For all employees of the ICU to:
- Feel valued outside of work
- Be recognized for taking care of themselves
- Participate in positive discussions
- Be rewarded for work life balance
- Be reminded of self-care
- Not feel alone with their thoughts
- Pause and reflect
- Help others, spouses, kids, etc.
Future plans include:
- Seasonal questions of things to see, places to explore
- Recipe sharing
- Hobby experts
- Focusing on staffs' interests
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Accelerated Onboarding for Unlicensed Personnel When Preceptors Are Limited
Britney Winkelman
Problem:
The timeframe between hiring unlicensed personnel (UP) to beginning the role within the organization began to increase due to limited orientation resources, rising staff shortages, and insufficient number of preceptors.
Purpose:
Accelerate the onboarding of UPs to decrease the workload for preceptors and reduce staff shortages, while generating competence and reducing costs for the organization.
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NeuroInterventional Post-Procedure Assessment and Documentation Compliance
Chandra Brower
Per stroke best practice guidelines, pulse and groin checks need to be completed post-neurointerventional procedure per orders. Our plan is to improve assessment and documentation of post-procedure pulse and groin checks by improving the flow of the Electronic Medical Record (EMR). By enhancing clinical documentation and improving the documentation process, nursing practice can be supported, and best patient care delivered.
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Very Important Discharge Appointment (VIDA)
Jennifer Burris, Holly Kockler, Gail Olson, Kristi Patterson, Natasha Pflueger, Jennifer Salzer, and LeAnn Volkers
To improve patient flow, access, and decrease strain on resources by enhancing the current process of Discharge and Loop Back Huddle by identifying two patients for early discharge the next day.
Current Practices:
- Discharge huddle and Loopback (Discuss care progression for all pts)
- Discharge planning using the IDEAL Model (Patient and Family Engagement with Discharge)
- Electronic Discharge Readiness Tools (Exp Discharge Date, Discharge milestones, etc.)
Next piece of the puzzle:
- VIDA: a framework to identify 2 patients to be discharged before 11 am – so the bulk of our discharges do not occur between Noon and 4:00 pm.
- Decreasing the strain on internal and external resources.
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Innovative Use of EHR to Support Admission Screening for Emerging Pathogens
Patricia Dumonceaux MSN, RN, CIC, PHN; Carolyn Harlander-Zimny; Elizabeth Kiffmeyer; Ellen Simonson; and Tamara Welle
- CentraCare hospitals were the first in Minnesota to identify a patient with Candida auris (C. auris), an emerging pathogen.
- 2018 Centers for Disease Control and Prevention (CDC) and state health department recommended adoption of enhanced admission screening process to allow for early identification of patients at risk of being colonized with C. auris/Carbapenem-Resistant Organisms (CROs).
- C. auris, a fungus, and CROs, comprised of organisms from the Enterobacteriaceae family resistant to carbapenems, are emerging multidrug resistant pathogens. Emphasis on identification and early isolation of at-risk patients decreases risk of transmission.
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ICU Liberation: Early Mobility and Exercise
Vanessa Fuller and Andrea Nyquist
ICU Liberation:
The Society of Critical Care Medicine’s (SCCM) Intensive Care Unit (ICU) Liberation Bundle was created to reduce the harmful effects of events that occur in the ICU setting. Early mobility and exercise is part “E” of the ICU Liberation Bundle; goals are to reduce ICU and hospital length of stay (LOS), prevent readmissions, reduce discharges to long term care facilities, reduce delirium and coma days, and reduce likelihood of hospital mortality (SCCM, 2021)
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Perioperative Glucose Monitoring Protocol
Nicole Helgeson
Currently, there is no established glucose management protocol for our surgical patients. Poor outcomes related to hyperglycemia may include increased morbidity/mortality, surgical site infection (SSI), sepsis, renal, and cardiac concerns. The purpose of this protocol is to improve the care and outcomes for surgical patients through a consistent standardization of glucose management.
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A Multidisciplinary Approach to Reduce Complications from Blind Small Bore Feeding Tube (SBFT) Insertion
Teresa Jahn, Jennifer Burris, Peggy Lange, Elizabeth Plante, and Mithun Suresh MD
Between 2019 and 2021, six lung perforations related to blind placement of SBFTs.
A multidisciplinary team reviewed current methods of placing SBFTs and the feasibility of each:
- Fluoroscopy
- 2 Step X-Ray
- Capnography
- Electromagnetic visualization
Capnography was selected as a safe and cost-effective way to attempt to identify insertion location in real time.
- Four team members were selected and trained to insert SBFT using capnography
- Each placement attempt and outcome of placement was tracked
- Outcomes were identified as successful or unsuccessful
- Any adverse events were to be tracked
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It's Time to Break Old Habits: Admitting STEMIs to the Telemetry Unit
Teresa Jahn and Tanya Glenz
Beginning December 2020 uncomplicated ST-Elevated MI patients will be admitted directly to Telemetry following intervention instead of CICU.
June 2020: Review and develop evidence- based exclusion criteria for admission to Telemetry
June 2020: Create a process for communication between the nursing supervisor, cath lab, Telemetry Unit and CICU for patient placement
Fall 2020: Meeting with Telemetry and CICU charge nurse, nursing supervisor and cath lab RN to discuss communication process
Dec 2020: Begin tracking STEMI patients
- Unit admitted to (Telemetry or CICU/ICU)
- Requiring transfer to CICU/ICU from Telemetry
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PureWick External Female Catheter
Elizabeth Kiffmeyer and Mallory Mondloch
Catheter-Associated Urinary Tract Infection (CAUTI) rates increased in FY21 compared to FY20, and many units continue to not meet their National Database of Nursing Quality Indicators (NDNQI) target goal even through FY22.
A group of CentraCare stakeholders gathered, including bedside nursing staff, urology techs and nursing leadership, to discuss barriers and areas for opportunity. Representatives from BARD®, our urinary catheter supply company, were invited to conduct an analysis on our urinary catheter/ CAUTI reduction practices. Findings from the analysis included an opportunity to implement an external female catheter.
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Early Detection of Sepsis
Holly Kockler and Evalyn Michira
The aim for this project was to improve early identification and intervention for sepsis to lower mortality rates and increase sepsis order set usage.
Key Drivers:
- Sepsis mortality rate is higher than compare groups
- Sepsis Order Set utilization is low
- Sepsis core measure performance is below benchmark
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Improving the Management of Tardive Dyskinesia on an Inpatient Mental Health Unit
Jennifer Krebsbach
Implement a practice change on the adult mental health unit to improve the accuracy and increase the rate of completion of the abnormal involuntary movement scale (AIMS) for tardive dyskinesia (TD).
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CentraCare Launch of COVID Antiviral Therapy
Jessica Miller, Todd Lemke PharmD, and Dennis Heinen RPh
- Efficiently monitor the limited available stock of oral antiviral COVID therapies during surge states
- Prescribe safely and appropriately
- Dispense to patients close to home.
Nurses at CentraCare Health are engaged in finding ways to improve all aspects of practice of nursing in the clinical setting. The following are posters created in the process of Evidence-based Practice Projects and clinical improvement.
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