NY Nurses Help Hospitals Realize Better Outcomes, Lower Health Care Costs Through AACN CSI Program

Small teams of nurses at seven New York hospitals have improved patient care and saved their hospitals millions of dollars by participating in a training program conducted by the American Association of Critical-Care Nurses (AACN).

The New York hospitals were the sixth cohort in the program. So far 42 hospitals nationwide have participated in the AACN Clinical Scene Investigator (CSI) Academy, a 16-month nursing leadership and innovation training project that has improved patient outcomes and saved hospitals more than $28 million annually.

In the New York cohort, groups of four nurses from each hospital chose a treatment area they wanted to address, such as preventing hospital-acquired infections and falls or standardizing protocols to assessing delirium or mobilizing ventilated patients, reports Nurse.com.

At North Shore University Hospital, nurses focused on reducing catheter-associated urinary tract infections (CAUTIs) in the intensive care unit (ICU), because their unit had the highest rate in the state’s health system. Interventions included education efforts for patients, staff, and families on the importance of earlier removal of the catheter, and a focus on hygiene practices. After implementing the changes, the hospital achieved more than six months without a CAUTI, a significant improvement from not having a single CAUTI-free month before the academy. The reduction in infections saved $112,000 for the hospital.

At NYU Langone Medical Center nurses wanted to establish a consistent approach to treating and assessing delirium in the medical ICU. They collaborated with the care team, including the IT department, which developed a way to incorporate delirium assessment into electronic health records. Innovations also included an assessment checklist for delirium printed on mousepads, which eliminated the need to search for the tool. The Center estimates it will save between $3.3 million and $5.5 million as a result of the changes.

Nationwide, the CSI Academy has trained 163 nurses to address clinical challenges such as hospital-associated infections, pressure ulcers, delirium, early mobility, falls, and patient handoffs. Project materials developed by each team, including plans, data collection tools, practice resources and references in a searchable online database, are available on the AACN website at www.aacn.org/csiprojects.

The INQRI Blog featured previously released data from the Academy from regional groups working in Massachusetts and North Carolina and overall progress in the program.

CLASBIs Rates Improved When Hospitals Implement Airline Industry Approach

Hospitals around the country are reducing central line associated bacterial infections (CLASBIs) by taking a “plane crash” instead of a “car crash” approach in their efforts, according to a VOX special report.

The theory is that car companies see accidents as unavoidable, no matter how much work goes into prevention. The aviation industry, however, treats each crash as potentially preventable and investigates how it could have been prevented. A similar divide exists among hospitals when it comes to treating CLASBIs central line infections, Vox reports.

While some hospitals view the infections as bad but inevitable, other hospitals “see each central line infection as a failure that requires investigation and better preventive techniques in the future.” And many of these “plane crash” hospitals are reducing infections, in part by empowering nurses and giving them the tools to prevent infections.

Peter Pronovost, a critical care physician at Johns Hopkins University in Baltimore, created a simple five-item checklist that centers on cleanliness when inserting central lines, and changing the dressing, and implementing changes such as centralized stock carts. But one of the most significant changes the hospital implemented was to instruct nurses to “call out” doctors who were not following checklists. Within three months, CLASBIs decreased by 50 percent, and they decreased by 70 percent after six months.

Hospitals in Michigan and California Follow Suit

After hearing of the success at Johns Hopkins, the Michigan Hospital Association implemented a similar the protocol at about 60 hospitals in the state, and realized a 70 percent decrease within three months. Similarly, Roseville Medical Center in California implemented its own version of Pronovost’s checklist and also gave an 18-nurse vascular access team exclusive responsibility for inserting and monitoring central lines. For seven years after the new program was instituted, Roseville did not have a single central line infection.

When the hospital’s seven year streak broke in 2014, Roseville decided to investigate. The investigation revealed that subcontracted nurses who treated dialysis patients, but who were not part of the central line team, were responsible for the infections. As a result of the findings the hospital now requires annual competency checks for contract nurses who manage central lines.

“The Roseville response mirrors what airlines do at a moment of crisis: analyze the situation and implement new policies that could prevent the same type of problem in the future.”

Reducing CLASBIs was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.

The full VOX article is available here.

Intervention Efforts Leads to Reduced Risk for Liver Patients

A nurse-led intervention improved rates of vaccination for Hepatitis A and Hepatitis B for patients awaiting liver transplantation, ultimately reducing the risk of disease and other post-transplant complications, according to an article in Medscape Medical News.
 
During the American Association of Nurse Practitioners 2015 National Conference Shari Perez of the Mayo Clinic in Scottsdale, Arizona told attendees that patients were nearly 9.5 times more likely to complete the vaccination series after a nurse intervention system was implemented at the clinic.

The new protocol incorporated a vaccine tracking system using the department database, and improvements to order entry for required vaccines and vaccine-scheduling practices.  The protocol also involved patient mail-in vaccination cards and an electronic medical record patient-flagging system for providers.

The full article is available here. (Free registration required.)

Nurse-led Intervention Successful in Increasing Older Patients' Activity Levels

Nurse-led primary care interventions can lead to sustained increases in physical activity (PA) among older adults, according to a recent article published in PLOS Medicine by lead author Tess Harris of St George's University of London. Additionally, the participating patients indicated that they felt positively about the intervention, reports Medical Xpress.

Researchers enrolled nearly 300 people ages 60-75 in the trial, and randomly separated them by household, to receive either standard care or the nurse-led intervention. Primary care nurses delivered PA consultations over a three month-period to the intervention group, providing individualized activity plans and feedback on data recorded from pedometers and accelerometers worn by the patients.

At the three month mark, the intervention group reported that they took 1,037 more steps than the control group. Additionally, the intervention group spent 63 more minutes per week in PA sessions of 10 minutes or more. There was a sustained gap at the 12-month mark, although it decreased to 609 steps per day and 40 minutes per week.

The trial, funded by the National Institute for Health Research, suggests that this type of nurse-led intervention may be an effective way to increase PA in older adults, resulting in better health. However, the researchers said that additional trials are needed to discover what aspects of the intervention were most effective and how it would work in larger and more socio-economically diverse populations.


INQRI grantees Barbara Resnick and Sheryl Zimmerman also found success with an intervention designed to deliver Function Focused Care to residents in assisted living facilities. Their intervention was designed to maintain and improve function, PA, muscle strength, psychosocial outcomes (efficacy expectations and life satisfaction) and decrease adverse events (pain, falls and hospitalizations) among assisted living residents. Residents in intervention treatment sites demonstrated fewer declines in function and spent more time in moderate level physical activity at 4 months and more overall counts of activity at 12 months when compared to residents in control sites. There were also fewer transfers to the hospital among those in the treatment sites.

Nurse-Led Interventions Reduced Shortness of Breath, Fatigue in Lung Cancer Patients

A nurse-led symptom management program conducted in Canada showed improvements for patients with lung cancer in the areas of dyspnea, or shortness of breath, and fatigue. Nurses provided patients with information and support, according to a study presented at the Oncology Nursing Society (ONS) 39th Annual Congress.

Researchers at the Grand River Regional Cancer Centre in Kitchener, Ontario, Canada, conducted the study in partnership with the Dyspnea Management Clinic. Oncology nurses used the results of an assessment of patients’ understanding of their symptoms to develop a protocol for patients with underlying lung cancer, Oncology Nurse Advisor reports. The protocol included:

• Assessment of breathlessness,
• Understanding the meaning of symptoms,
• Recognition of problems that require medical intervention,
• Offering breathing retraining,
• Use of relaxation technique, and
• Goal setting.

Each of the 43 patients participating received a one-hour consultation combined with follow-up visits. Their understanding of symptoms was measured by advanced nurse practitioners. The nurses could then implement a comprehensive approach to address dyspnea symptoms. Scores for dyspnea and tiredness were significantly improved in all patients when compared to a previous control group of 40 patients. The results demonstrate that oncology nurse-led interventions are effective methods for improving symptom management in patients with lung cancer, according to the researchers.

The role of nurses in providing care to cancer patients was explored by an INQRI team at the University of Utah. Led by Susan Beck, this interdisciplinary team designed a robust measure to assess adult patients’ opinions about how nurses manage cancer-related pain. Beck and her team developed an instrument using qualitative and quantitative data to elicit patients’ opinions about how their nurses and other members of their care team managed their pain and, ultimately, to help patients select hospitals based on this dimension of their care experience.

Nurses Can Effectively Use Hospital Approach to Infection Prevention in Dialysis Settings

Safety assessment tools and interventional approaches, such as those used by nurses in hospitals, are also effective in reducing catheter-related blood stream infections (CRBSIs) in outpatient dialysis settings, Nephrology News & Issues reports.

The study, A Pilot Quality Improvement Program to Minimize Catheter-Related Bloodstream Infection in an Outpatient Hemodialysis Setting, was presented at the 45th annual meeting of the American Nephrology Nurses Association. Research was led by Nancy Culkin of DaVita HealthCare Partners, a specialty contract research organization focusing on drug and device development.

The study concludes that approaches which have successfully reduced CRBSIs in hospitals can be applied in chronic dialysis facilities, including procedural kits with materials such as: a checklist, antimicrobial swabs for skin prep, triple antibiotic ointment for onsite application, alcohol swabs to facilitate hub scrub, and exit site dressing.

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of central line-associated bloodstream infections. The study was conducted by David Thompson and Jill Marsteller, associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton, now at the Duke University Health System Patient Safety Center.

“It’s important to note that this was a nurse-led intervention,” Marsteller said. “The units’ success in reducing infections not only demonstrates the effectiveness of the intervention, but also confirms that nurses can have and should play a central role in quality improvement interventions.”

Nurse Navigator Intervention in Cancer Treatment Effective and Efficient

A new study finds that nurse navigators provide crucial emotional support and guidance for people diagnosed with cancer. Additionally, patients report significantly fewer problems with care as a result of nurse intervention.

The study, “Nurse Navigators in Early Cancer Care: A Randomized, Controlled Trial,” was published in the November Journal of Clinical Oncology. It focused on whether nurse navigator intervention improved quality of life and patient experience for 251 adults recently given a diagnosis of breast, colorectal, or lung cancer. 

Researchers found that patients who had access to a nurse navigator soon after diagnosis reported feeling that they had better emotional support, were better informed, and were more involved in their care, Medscape Medical News reports. Patient outcomes typically improve when patients are more involved in their care and self-care, researchers said.

For the study, 118 participants were randomly assigned to receive oncology nurse navigator support and 133 received enhanced usual care (the control group). Patients in the intervention group received weekly phone calls from a nurse navigator and met with that nurse in person at least once during the four-week period. The control group received educational material designed by a patient advisory committee.

Nurse Navigator Intervention Effective and Efficient

Patients in the nurse navigator group reported significantly better scores on the Patient Assessment of Chronic Illness Care and had significantly fewer problems with care, especially psychosocial care, care coordination, and information, according to the study.

The intervention also yielded an unanticipated cost benefit. While cumulative costs after diagnosis did not differ significantly between the two groups; costs were $6,852 less for lung cancer patients in the nurse navigator group.

The nurse navigators involved in the trial had previous experience with cancer patients and received special training to deal with psychosocial distress, which may have been factors in the success of the interventions, according to Edward H. Wagner, MD, MPH, the lead author. Wagner is senior investigator at Group Health Research Institute.

The benefits for disadvantaged patients may be even greater than those found in this study, researchers said. The trial intervention participants were generally well educated, insured, and of higher income.