Glossary
EP - Exemplary Professional Practice

EP1EO: Describe and demonstrate the result(s) of applying the Professional Practice model. Include two (2) examples related to nursing Practice, collaboration, communication, or professional development activities.

Findings:

Example 1: CAUTI bundle and handoff Tool: a result of the application of the Professional Practice Model was not demonstrated

  • The time period for intervention was not clear as the data displayed on the graph were identified as occurring in the first quarter of 2011; however the handoff tool from was developed with a date of June, 2011 and the guidelines for use of the tool became effective in July 2011.
  • Pre-data for the three quarters before the period of intervention (fist and second quarters 2011) was the same as for the three quarters after, two quarters with “0” and one quarter slightly above 0

Example 2: Neonatal IV infiltrations: a result of the application of the professional practice model was not demonstrated:

  • The time period of the intervention was unclear. The only intervention date identified was on august 2012 educational slide presentation which was after the presentation of the pre-initiative (second quarter 2010) and post initiative data (first quarter 2012)

Resolution:

  • Time Period clarified
  • Additional Data provided

Example 1: CAUTI bundle and Handoff tool

Purpose/Background:

The Critical Care Division embraces the Patient Centered Family focused (PCFF) model, by placing the patient and family at the center of care delivery. In January of 2011, an increase in the rate of Catheter Associated Urinary Tract Infection (CAUTI) was identified. A review of best practices and an evaluation of the CAUTI prevention procedures identified the need to strengthen the use of CAUTI bundles. The professional practice model was applied to enhance the process by nursing staff.

Goal:

  • Return to a CAUTI rate of zero and sustain results and maintain below the NDNQI teaching facilities national comparative mean.

Participants and Participating Units:

All staff RNs in the ICU and CCU participated in this initiative.

The Leadership team that spearheaded this initiative included:

  • Christina Simeone BSN, RN – Critical Care Division Manager
  • Nicole Sardinas MSN, RN, CCRN – Clinical Educator
  • Claudia Garzon Rivera MSN, RN, CCRN, CNL – Clinical Nurse Leader
  • Mabel LaForgia MSN, RN, CCRN, CNL- Clinical Nurse Leader

Nursing Champions:

  • Erin Salmond BSN, RN – Charge RN
  • Alana Kearney BSN, RN – Staff RN
  • Melissa Massa BSN, RN – Staff RN

Methods:

  • Developed an interdisciplinary plan of care/ handoff tool that reinforces CAUTI bundles
  • Incorporate the newly developed tool during interdisciplinary rounds for reinforcement of CAUTI bundles

The patient centered family focused model led to the development of an interdisciplinary rounding/handoff tool. This tool is used by staff RNs to formulate and document an individualized plan of care. During interdisciplinary rounds healthcare providers review and contribute to the plan of care. The tool is then used by the nursing staff during handoff to enhanced communication during transfer of care to the next provider.

The tool reinforces the use of all ICU collaborative including CAUTI. This tool allows the interdisciplinary team to discuss specific elements of the bundle reinforcing best practices.

Please refer to 0011 for the full Professional Practice Model schematic.



Timeline:

January 2011: An increase incidence of CAUTI rates in the ICU and CCU led to development of the new interdisciplinary plan of care/handoff tool. Please refer to Appendix EP1EO-A for a copy of draft form.
February 2011 1st draft of the tool was developed. The Tool was piloted and reviewed by nursing staff in both ICU and CCU. Modifications were made based on recommendations by nursing staff.
March Draft with changes submitted for print.
April First proof obtained and presented to staff for review and approval of changes. Additional changed requested by nursing staff (Appendix EP1EO-B).
May Form was presented to critical care committee for approval (Appendix EP1E0-C). Additional modifications to the form were made (Appendix EP1EO-D).
June All changes were approved by nursing staff. A Guideline was drafted and distributed to staff for review.
July Guideline was approved by policy committee. The new process with the use of the interdisciplinary rounding/ handoff tool was implemented by all staff nurses in ICU and CCU. Nurse champions encouraged and promoted the use of the tool.

Outcomes

Pre-Implementation Data

EP1EO_chart1 

EP1EO_chart2 

Post Implementation Data

EP1EO_chart1 

EP1EO_chart2 

The post implementation data reveals that the CAUTI bundle and handoff Tool which were developed as a result of the application of the Professional Practice Model was demonstrated. This intervention successfully sustained a decrease in the incidences of CAUTI in both the ICU and CCU.

Neonatal IV infiltrations

Purpose/Background:

The Neonatal Intensive Care Unit (NICU) has always embraced the Patient Centered Family Focused Model by placing patients and parents at the center of their care delivery. An increase in the rate of peripheral intravenous (PIV) infiltrations occurred during the first quarter of 2011. These injuries are often preventable through the implementation of best practices. The professional practice model was applied to establish and reinforce a rigorous process for ongoing monitoring of intravenous access sites by nurses and all members of the healthcare team.

Goals:

  • Return and sustain PIV infiltration in the NICU to a rate of zero and maintian below the NDNQI teaching facilities national comparative mean.

Participants and Participating Units:

All staff RNs in the NICU participated in this initiative

Person spearheading this initiative:

  • Michelle Dickerson MSN, RN-C NEA-NIC – Clinical Educator for the NICU

Unit Champion:

  • Jocelyn De La Cruz BSN, RN- Staff nurse NICU

Methods:

  • Establish a process with the nursing staff to Adopt a hyper-vigilant approach to monitoring intravenous access in the NICU population
  • Implement best practices for prevention of PIV infiltrations

Michelle Dickerson used the Patient Centered Family Focused Model to establish a culture of safety by reinforcing continuous monitoring of intravenous access sites and aseptic PIV insertion techniques. Ms Dickerson worked with staff nurses to improve the standards of practice with PIV insertion, assessment, visualization, documentation, and infiltration prevention strategies. A self learning module with post test, regarding IV essential was developed by Ms. Dickerson. This tool was used to educate nursing staff regarding best practices ( Appendix EP1EO-E, EP1EO-F). Ms. Dickerson reinforced the content by providing one to one education daily to each nurse who had a patient with an IV. She rounded daily with the nursing staff to educate and reinforce the criteria for identifying PIV infiltrates, provided guidance on how to manage peripheral IV infiltrates, and assured appropriate documentation. For example, one of her main findings was that nurses frequently covered their PIV sites with gauze dressings. Ms. Dickerson emphasized the importance of applying transparent adhesive dressing to facilitate visibility. This process led to enhanced communication and collaboration between nurses, family members and the interdisciplinary team.

Jocelyn Delacruz BSN, RN also championed this initiative by conducting monthly peripheral intravenous infiltration audits (Appendix EP1EO-G). During this audit she observes all patients with PIVs and visually assesses each site for which a fluid or medication is infusing or was infusing during the last hour. If an infiltration is assessed Ms. Delacruz grades the extent of injury. This information is shared with the nursing staff and provided to the JCMC Performance Improvement Department

EP1EO_chart5 

JCMC professional Practice Model Schematic Elements

Application of JCMC’s Professional Practice Model in the Neonatal Intensive Care Unit

 

Michelle Dickerson used the concepts of accountability, autonomy, communication, excellence and team work to address the increase in PIV infiltrations in the NICU. Patient and Family members are an integral part of the care provided in the NICU

Care Coordination:  Care is coordinated among all member of the healthcare team. PIVs are evaluated throughout the entire continuum of care.

Safety:   Decreasing PIV infiltrations in the NICU contributes to safe care and decreases the potential for patient harm.

Clinical Quality:   The Implementation of best practices by the nursing staff contributes to quality care.

Economic Health:  Reducing PIV infiltrates will improve the economic health of JCMC.

Benner - Novice to Expert:  The Neonatal Intensive Care Unit’s Annual Nursing competency includes IV cannulation insertion. This is evaluated using Benner’s Model from Novice to Expert. Please refer to (Appendix EP1EO-H). 

Watson -  Human Caring:  The increase in PIV infiltration rates in the NICU was addressed using one of Jean Watson’s Ten Caritas Processes which states “Use creative scientific problem-solving methods for caring decision making”. The nurses used evidence based practices to prevent PIV infiltrations.

Communication 

Communication was enhanced between nurses, physicians, and family members regarding the status of PIV sites.

Trust

 Open communication regarding PIV infiltrations increases trust between family members and the healthcare team.

Team Work

The IV is assessed daily for infiltrations during interdisciplinary rounding. Pharmacy also collaborates with the nursing staff to ensure that medications are appropriately diluted and safe for the neonate

Excellence

 To promote excellence in patient care evidence based measures were implemented an reinforced

Accountability

Staff nurses were held accountable to assess PIV sites hourly or swelling, blanching, redness, and signs of pain or leakage. As soon as an IV infiltrate was identified or suspected, it is the expectation that the IV is removed immediately and treatment is provided as needed.   


2011 Timeline:

January – March: Increase in the rates of PIV site infiltrations was identified
April – June:

Self learning packets were distributed to staff. Ms Dickerson began providing one to one education and mentoring to nursing staff. Monthly audits of PIV infiltration were in progress.

The following evidence based measures were reinforced in the NICU:

  • Monitoring of PIVs by all nurses and physicians
  • Enhanced communication between nurses, physicians, and family members regarding IV status
  • Daily assessment of PIV infiltrates during interdisciplinary rounds
  • Hourly assessments of PIV sites by RNs
June Policy for saline lock maintenance developed and approved through the Policy Committee
July – September Ongoing education and support provided by Michelle Dickerson continues. Infiltration rate are zero for the quarter.
October – December Interventions maintain ongoing and continue in 2012. Further education is provided as needs are identified

Outcomes

Pre-Implementation Data

EP1EO_chart5 

Post Implementation Data

EP1EO_chart6 

The post implementation data reveals that the interventions implemented by Ms Dickerson and the nursing staff as a result of the application of the Professional Practice Model were demonstrated. This intervention successfully sustained a decrease in the incidences of PIV infiltration in the NICU.