Critical Care Resource Nurse Team: A Patient Safety and Quality Outcomes Model.

The Critical Care Resource Nurse Team (CCRNT) evolved from our traditional Rapid Response Team (RRT). The CCRNT is a unique paradigm created using the conceptual framework of the American Association of Critical Care Nursing Synergy Model for Patient Care. The goal of the CCRNT is to help align nurse competencies with patient needs. This team was seen as a much-needed strong clinical support by nursing leadership as large numbers of inexperienced new graduate registered nurses were hired and senior experienced nurses were leaving the workforce. The CCRNT supports 24/7 RRT, Code Blue, Code Stroke, Emergency Airway Response Team, Early Warning System, Medical Emergency Team, simulation team training, and bedside nurse support and mentoring. Coverage expanded from inpatient medical/surgical areas to all areas of the medical center and included hospital-wide initiatives. The focus for the CCRNT changed to a system-wide nursing and patient safety model to improve practice and intervene in near-miss events. This model improved communication between disciplines, provided critical surveillance of at-risk patients, supported patient safety with a significant decrease in patient mortality, and offered a 24/7 expert critical care nurse resource team for staff.

Medical emergency kits in ambulatory care clinics.

Implementation and staff perceptions of usability and feasibility.

Oral Care Clinical Trial to Reduce Non-Intensive Care Unit, Hospital-Acquired Pneumonia: Lessons for Future Research.

Hospital-acquired pneumonia (HAP) contributes greatly to patient mortality and healthcare costs. Studies have shown that aggressive oral care in intensive care units (ICUs) can significantly reduce pneumonia rates, and hospitals have implemented stringent protocols in this setting. However, little is known about the effectiveness of aggressive oral care in reducing HAP in non-intensive care wards, prompting us to conduct a nonrandomized controlled clinical trial. A structured toothbrushing program was provided to an experimental cohort of patients. A control group received usual care. Patient demographics, toothbrushing frequency, and pneumonia diagnosis were recorded over a 3.5-month period. Difference in pneumonia rates was computed using unadjusted and multivariate logistic regression analyses. No significant difference in pneumonia rates between control and experimental groups was found (1.7% versus 1.8%). Toothbrushing rates increased significantly in the experimental group (p = .002) but fell short of protocol frequency. It became apparent that aggressive toothbrushing program implementation requires nursing-led interdisciplinary involvement, more intensive training, a streamlined documentation system, and efficient compliance tracking. Lessons from this study should be used for future large-scale research. A secondary analysis of these data did, however, suggests that increasing toothbrushing rates may have the potential to reduce pneumonia in the non-ICU acute care setting.

Emergency Airway Response Team (EART) Documentation: Criteria, Feasibility, and Usability.

Patients in an acute care hospital who experience a difficult airway event outside the operating room need a specialized emergency airway response team (EART) immediately. This designated team manages catastrophic airway events using advanced airway techniques as well as surgical intervention. Nurses respond as part of this team. There are no identified difficult airway team documentation instruments in the literature, and the lack of metrics limits the quality review of the team response. This study identified EART documentation criteria and incorporated them into a nursing documentation instrument to be completed by a nurse scribe during the event. The EART instrument was tested by nurses for usability, feasibility, and completeness. Twenty-one critical care nurses participated in this study. The results confirmed good usability, positive feasibility, and 79% documentation completeness using this tool. These criteria and this instrument can be important in documenting the EART and in evaluating the quality of the team performance.

Emergency Airway Response Team Simulation Training: A Nursing Perspective.

BACKGROUND: Simulation-based education is an important tool in the training of professionals in the medical field, especially for low-frequency, high-risk events. An interprofessional simulation-based training program was developed to enhance Emergency Airway Response Team (EART) knowledge, team dynamics, and personnel confidence. This quality improvement study evaluated the EART simulation training results of nurse participants. METHOD: Twenty-four simulation-based classes of 4-hour sessions were conducted during a 12-week period. Sixty-three nurses from the emergency department (ED) and the intensive care units (ICUs) completed the simulation. Participants were evaluated before and after the simulation program with a knowledge-based test and a team dynamics and confidence questionnaire. Additional comparisons were made between ED and ICU nurses and between nurses with previous EART experience and those without previous EART experience. RESULTS: Comparison of presimulation (presim) and postsimulation (postsim) results indicated a statistically significant gain in both team dynamics and confidence and Knowledge Test scores (P < .01). There were no differences in scores between ED and ICU groups in presim or postsim scores; nurses with previous EART experience demonstrated significantly higher presim scores than nurses without EART experience, but there were no differences between these nurse groups at postsim. CONCLUSIONS: This project supports the use of simulation training to increase nurses' knowledge, confidence, and team dynamics in an EART response. Importantly, nurses with no previous experience achieved outcome scores similar to nurses who had experience, suggesting that emergency airway simulation is an effective way to train both new and experienced nurses.

Nurse Residency Program Designed for a Large Cohort of New Graduate Nurses: Implementation and Outcomes.

A nurse residency program was designed to train a large group of new graduate nurses hired into multiple specialty areas. The program included a generalist 1 month 5 day/week clinical orientation followed by specialty clinical orientation with ongoing generalist education. Retention rate after 1 year was 91%.

Standardizing nurse training strategies to improve knowledge and self-efficacy with tracheostomy and laryngectomy care.

OBJECTIVE: Appropriate tracheostomy and laryngectomy care requires that nurses maintain specific knowledge and a particular skillset, to ensure safe, competent care. Deficiencies in this nursing care remain a persistent problem. The objective of this study was to evaluate the effect of a nurse training program on knowledge and self-efficacy with tracheostomy and laryngectomy care. STUDY DESIGN: Prospective, interventional survey design. SETTING: Academic, tertiary care hospital between September 2014 and April 2015. SUBJECTS AND METHODS: 1450 nurses at an academic tertiary care hospital were surveyed on tracheostomy and laryngectomy care at two time points: before and after the implementation and completion of the nurse training program. The nurse training program included a hands-on training session and online tutorial on appropriate tracheostomy and laryngectomy care. 732 nurses completed the hands-on training and were asked to complete the online tutorial. A total of 338 surveys were collected. Survey data were collected through an online survey development platform. Analyses were performed using SAS software. Chi-square tests and t-tests were utilized with a significance level of 0.05. RESULTS: 165 pre-training surveys and 173 post-training surveys were completed. Statistical analysis of the post-training data demonstrated statistically significantly higher knowledge and self-efficacy scores of nurses who completed the training than nurses who did not. CONCLUSIONS: Findings from this study reveal poor overall nursing knowledge and self-efficacy with this care and suggest that optimizing and standardizing nurse training is an effective strategy to improve nursing knowledge and self-efficacy with head and neck surgical airways.

Comprehensive Emergency Airway Response Team (EART) Training and Education: Impact on Team Effectiveness, Personnel Confidence, and Protocol Knowledge.

OBJECTIVE: To evaluate the efficacy and utility of simulation of the Emergency Airway Response Team (EART) at a tertiary care hospital to improve team dynamics and confidence and knowledge in managing an emergency airway. METHODS: This was a descriptive, quantitative performance improvement study. From September 1, 2013, to December 1, 2013, 177 members of the EART from anesthesia, otolaryngology, trauma surgery, emergency medicine, ICU nursing, and respiratory therapy participated in emergency airway simulations. Team dynamics and confidence levels and knowledge of EART were assessed using pre-and post-simulation questionnaires. RESULTS: All participants regardless of their role, experience in the medical field, or any prior exposure to a difficult airway showed significant improvement in self-rated team participation and confidence and objective knowledge regarding EART after undergoing simulation. CONCLUSION: Our study highlights the efficacy and utility of simulation in assessing personnel team dynamics and confidence levels and knowledge of emergency airway scenarios. Practitioners in all fields and level of experience benefit in EART training and simulation. We hope that with this information, we will be able to conduct future studies on reduction of patient morbidity and mortality.

Cardiac monitoring: Hospital-wide education and staff competence.

BACKGROUND: The numbers of patients in acute care hospitals who require cardiac monitoring are increasing. Unpredictable fluctuations in patient flow may result in shortages of telemetry beds for patients who need this level of care. OBJECTIVE: The aims of this study were to design and implement cardiac monitoring education for all medical-surgical nursing staff in a level I trauma center. METHODS: This is a descriptive, quantitative performance improvement study. A multidisciplinary implementation plan was developed with biomedical engineering and physical facilities coordinating structural changes and nursing coordinating education and clinical competency. The nursing educational plans included a dysrhythmia course and testing, a clinically based competency, and a statistical analysis of the dysrhythmia test. The impact of this project was evaluated looking at areas transitioned, telemetry beds available, cardiac dysrhythmia education workshops, and dysrhythmia test results. RESULTS: The implementation of cardiac monitoring was completed over 2 years. Monitored medical-surgical beds increased from 132 to 282 beds. The nursing education expanded hospital-wide to clinical areas requesting standardization of nursing practice. CONCLUSIONS: In addition to expanding the number of monitored beds and decompression of critical care beds, benefits included increased level of staff competence, standardization of cardiac monitoring practices throughout the facility, and validation of the cardiac dysrhythmia test.

Translating guidelines into practice: ventilator-associated pneumonia prevention strategies in an acute rehabilitation unit.

Ventilator-associated pneumonia has significant mortality (33%-50%). The highest risk of ventilator-associated pneumonia is early in mechanical ventilation with an increase in morbidity and mortality seen with late-onset ventilator-associated pneumonia. Prevention strategies have been recommended for acute care facilities, but there is lack of evidence-based data and recommendations for acute rehabilitation units. A multidisciplinary team designed an evidence-based ventilator-associated pneumonia prevention policy based on the Institute for Healthcare Improvement ventilator bundle. Education of rehabilitation staff and implementation of the protocol were done. Results showed that the ventilator-associated pneumonia rate decreased from 7.5 to 0 per 1000 patient ventilator days. Translating evidence-based guidelines into practice can be accomplished using a multidisciplinary team.

Evidence-based practice, clinical simulations workshop, and intravenous medications: moving toward safer practice.

In an era of increased emphasis on medication safety practice, a gap exists in the translation of research to clinical practice for administering intravenous continuous infusion medications. An educational initiative was designed for medical-surgical nurses in a tertiary care center to standardize operational procedures in a clinical model focusing on evidence-based practice.

Standardizing adult tracheostomy tube styles: what is the clinical and cost-effective impact?

Tracheostomy tubes are made of a variety of materials, components, and styles. In a recent merger of our hospitals, we noted a large assortment of tubes available for clinicians. The different tubes resulted in complaints from staff, which included confusion, delays in obtaining preferred tubes, and inconsistent shelf stock. A multidisciplinary task force was formed to recommend standardizing the styles of tracheostomy tubes. A comparison of tracheotomy procedures, tracheostomy tube usage, and tube costs were done 6 months before and 6 months after the standardization. The number of tube styles decreased from 9 to 4; specialty extra-long tubes decreased from 3 to 2. There were no cost savings in standardizing the tracheostomy tubes.

Neurologic assessment skills for the acute medical surgical nurse.

Practical and efficient neurologic assessment skills are vital for acute care nurses. During an acute neurologic event, the nurse needs a focused assessment of the pertinent history and symptom analysis and an immediate head-to-toe survey, eliciting any abnormal signs to identify and correctly report the medical problem. When a patient requires routine monitoring of neurologic signs, the nurse's role includes a neurologic assessment, collecting and assimilating that data, interpreting the patient problem, notifying the physician when appropriate, and documenting that data. This article presents an overview of a staff nurse's neurologic assessment, explains common neurologic tests performed at the bedside, identifies an efficient way to perform the assessment, and indicates what to include and document when "neuro signs" are ordered.

New graduate RNs in a float pool. An inner-city hospital experience.

Nurse managers and nurse educators alike have historically discouraged hiring new graduate RNs into a float pool and have preferred experienced nurses with multiple clinical skills. With a nursing shortage and changing marketplace, we need different strategies for recruitment and retention and ways to improve our clinical practice. A new graduate RN offers a nursing service an opportunity to employ a motivated, ready-to-learn, educationally prepared and intellectually stimulated nurse who happens to have limited clinical experience. The authors present a program for training new graduate RNs to practice nursing in a float pool. The training program focuses on their clinical practice needs and on transitioning them to the RN role. This program resulted in a 96% retention rate. The program offered our medical surgical units a strong clinical support float nurse, our managers a staffing solution in times of need, and the new graduate RN a broad range of clinical experiences making them more valuable members of the healthcare team. This training model is one approach to increasing recruitment and retention and can be replicated in other institutions.