The CNL Role in Critical Care

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What can a Clinical Nurse Leader do for your critical care nursing unit? Plenty! Consider this new nursing role as one that can improve patient outcomes and increase satisfaction for both clients and …

What can a Clinical Nurse Leader do for your critical care nursing unit? Plenty! Consider this new nursing role as one that can improve patient outcomes and increase satisfaction for both clients and staff. Successful microsystems begin with empowering patients, families and front line nurses.

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  • Harris
  • Harris
  • Monaghan

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  • 1. Ann Deerhake, MS, RN, CNL, CCRN CNL USF Conference Logo 2011
  • 2.  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.
  • 3.  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?
  • 4.  Perform advanced patient assessments  Plan care/Change care  Empower frontline nurses  Partner with the interdisciplinary team  Grow clinically
  • 5.  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
  • 6.  Empower the patient  Assist with continuity of care  Promote evidence-based practice  Build collaborative relationships  Speak up!
  • 7.  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
  • 8.  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
  • 9.  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 barriers amongst strong personalities  Set your team apart from the rest setting a role model for excellence
  • 10.  Identify patient safety issues/risk  Develop realistic action plans  Promote systems thinking  Encourage others to get involved
  • 11.  Identify patient safety issues/risk focusing on reducing nosocomial infection  Promote systems thinking in addition to advanced critical thinking  Develop realistic action plans utilizing frontline staff knowledge  Encourage others to get involved as health promotion and safety officers
  • 12.  Encourage horizontal leadership  Meet personal CNL goals  Help other nurses reach their goals  Elevate the profession of nursing
  • 13.  Meet personal CNL goals within the context of critical care  Help other nurses reach their goals to become facility leaders and professional nurses as well as excellent caregivers  Elevate the profession of nursing and critical care nursing
  • 14.  Share what you know “knowledge transfer”  Be a coach  Research and disseminate  Formally present
  • 15.  Share what you know “knowledge transfer” it goes both ways!  Be a coach and an issue resolver in critical situations  Research and disseminate information on the fly and methodically planned  Formally present as an ICU nurse and educator
  • 16.  Improve communication  Reduce errors  Increase patient/family satisfaction  Increase recruitment/retention  Disseminate information using variety of methods
  • 17.  Improve communication between a large, multidisciplinary team  Reduce errors within a high acuity environment  Increase patient/family satisfaction within an incredibly stressful environment  Increase recruitment/retention of nurses with increased responsibility with minimal compensation  Disseminate information using variety of methods and electronic technologies
  • 18.  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 problems  reviewing peer literature  developing an action plan.
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. Patterns  Risk of EVD infection  No protocol for dressing changes FROM JULY 2008-JULY 2009 20% INCREASE IN EVD INFECTIONS! (NOSOCOMIAL VENTRICULITIS)
  • 23.  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
  • 24.  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
  • 25.  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
  • 26. 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 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
  • 27.  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 investigator  Small participant number (n=26)  Single facility study
  • 28.  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
  • 29.  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
  • 30. Harris, 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