By Marcia Frellick
Nurses working in small teams at seven New York hospitals have improved patient care and saved their hospitals millions of dollars with the help of a national program being rolled out at regional hubs across the country.
The New York hospitals were the sixth cohort nationwide to participate in the American Association of Critical-Care Nurses Clinical Scene Investigator Academy, a 16-month nursing leadership and innovation training project.
Groups of four nurses from each hospital chose the problem they wanted to tackle — from preventing healthcare-acquired infections or falls to standardizing protocols to assessing delirium or mobilizing ventilated patients.
In all cases, “nurses were leading the charge,” said Caryl Goodyear-Bruch, PhD, RN, NEA-BC, a senior director at AACN.
Each team chose the project that would have the most impact on patient care, she said, and then used evidence-based methods to make improvements. Even when more than one hospital chose the same problem, each team approached it in different ways, depending on their staff structure and unique environments.
6 months without a CAUTI
Nurses in the neurosurgical ICU at North Shore University Hospital, Manhasset, N.Y., targeted a reduction in catheter-associated urinary tract infections because their unit had the highest rate in the health system.
“We knew we had to get this problem under control,” said Launette Woolforde, EdD, DNP, RN-BC, the team’s coach and the hospital’s senior administrative director for nursing education. Woolforde said three of the seven hospitals in the New York CSI project targeted CAUTIs.
The neurosurgical unit’s patient population presented a particular challenge, according to Sherley John, BSN, RN, a staff nurse on the CSI team. Most patients present with complicated bleeds in the head, have neurogenic or dysfunctional bladders and typically stay in the units 21 days or more, which means long exposure to Foley catheters and more chance for infection.
“We knew if we could succeed there, we could succeed anywhere in the hospital,” Woolforde said.
Among the interventions was a substantial education effort for patients, staff and families on the importance of earlier removal of the catheter. The unit also had to change the staffing model since nurses were taking out the catheters earlier so that more hygienic care was available. Assistants were added who could clean the patients since there was more incontinence to save the staff nurses from burning out with the new protocol.
Visual cues to focus attention on the problem included a campaign on Fridays when nurses wore “Foley Friday” shirts and walked through the hospital answering questions from staff and visitors about the effort. They also put a prominent sunflower on the unit wall next to the board where nurses get their schedules. A petal was added for each day without a CAUTI.
In late March, the hospital had reached more than six months without a CAUTI, a dramatic improvement from not having a single CAUTI-free month before the academy, John said. They reduced number of device days by 31%. Based on the hospital’s data of $22,400 per CAUTI, the yearly cost savings was projected to be $112,000.
Maimonides cuts vent days
Thomas Smith, DNP, RN, NEA-BC, FAAN, the CNO and senior vice president, Maimonides Medical Center, Brooklyn, was integral in bringing CSI to New York.
He said though the evidence is available in literature to help solve these common problems, the AACN was able to provide financial and educational support to cover shifts and offer direction and structure during the length of the project.
In Maimonides’ medical ICU, they had seen an increase in the number of patients with alcohol and substance withdrawal. They chose to develop a nurse-driven protocol for assessment and treatment.
“Sometimes we oversedated people, and when you oversedate that affects their ability to breathe and sometimes [that] required mechanical ventilation,” he said.
In addition, staff also needed clear guidance for clinical management of the growing population of people coming in with withdrawal. The team called for use of the evidence-based Richmond Agitation Sedation Scale to assess patients’ withdrawal systems. They surveyed staff and found that before the change in protocol 17% were using RASS consistently. After the implementation, that number soared to 72%. Similarly, the numbers saying they were overwhelmed when they needed to manage a patient in delirium tremens/withdrawal went from 65% to 16% between the two surveys.
Smith summarized the results from September 2013 to February 2014: Total number of patients trached went from 11 to 1; total days on a ventilator decreased 59%; and total number of patients on a ventilator dropped by 50%.
The improvements have the potential to save the hospital an estimated $1.8 million a year, he said.
Now, Maimonides is rolling out the protocols to other ICUs at the hospital and the ED, along with adapting them for people who are less intensively ill in step-down and general medicine units.
“This is putting the nurse at the center of improvement, and we got the funding to do it,” Smith said. “They are proud, happy, ready to get going on other projects and impressing everybody in the organization. I can’t tell you how much energy it puts in my heart.”
At NYU Langone Medical Center, Manhattan, nurses realized a consistent approach to treating and assessing delirium in the medical ICU was lacking.
Ralph Carumba, BSN, RN, CCRN, assistant nurse manager of the unit, said they weren’t incorporating delirium into their plans of care and that gap can increase length of stay, ventilator days and likelihood of death. They collaborated with the care team, including the IT department, who developed a way to incorporate delirium assessment into the electronic health record, according to Carumba.
Among the improvements was an assessment checklist for delirium printed on mousepads to eliminate having to search for the tools. They also created a quiet time from 2-4 a.m. when patients’ doors are closed, and lights and phones are off to better delineate day and night.
The medical center calculated yearly potential savings in shorter length of stay with the delirium assessment in place, assuming 30% of the patients would present with delirium, at $3.3 million. If 50% presented with delirium, the savings would be $5.5 million.
Carumba, a bedside nurse when he started the program, said CSI advisers showed him that bedside nurses can lead the charge to make changes rather than carrying out leadership’s goals.
A seventh cohort is now in progress in Seattle. The next challenge for the program is discerning the best way to replicate results in other units and other hospitals nationwide.
Empowerment is at the heart of the program, according to AACN’s Goodyear-Bruch.
“We want nurses to feel they have a key role in their patients’ outcomes,” she said.
Marcia Frellick is a freelance writer.