NK - New Knowledge, Innovation, and Improvements

NK 7 The structure(s) and process(es) used to translate new knowledge into practice

Patient safety and clinical quality are strategic priorities for the Jersey City Medical Center’s Board of Trustees and for the clinical staff. Improving care outcomes and safety for patients is the primary reason for ensuring that evidence based practice is implemented regularly at JCMC. Through Structures and processes such as the IOWA model, involvement in national initiatives, and involvement of nursing leaders, Staff Nurses are empowered to bring best practices to the point of care. By doing so, nurses provide quality patient care and reduce potential harm to patients.

IOWA Model of Evidence Based Practice to Promote Quality Care

Since, 2006 the Nursing Research Council has utilized the IOWA Model of Evidence Based Practice because it infuses research into practice to improve the quality of patient care. It also focuses on the implementation and evaluation of EBP using a multidisciplinary approach.

The steps in the Iowa Model include:

  1. Select a topic or problem
  2. Form a team
  3. Find and Critique the evidence
  4. Adapt the evidence for use on specific unit
  5. Implement the evidence based practice
  6. Monitor and Analyze Structure, Process, and Outcome Data

Using the model as a structure to guide the implementation of evidence based practice at JCMC, the process begins with knowledge or problem focused trigger. If the problem is a priority for JCMC, a multidisciplinary team is formed consisting of key stakeholders such as clinician and staff nurses. A review and critique of the literature is done to determine if sufficient evidence supports the practice change. Then the new process is implemented on a specific unit. The process is monitored and outcomes are disseminated among other units. To view a discription of the Iowa Model of Evidence Based Practice to Promote Quality Care please refer to Appendix NK7-A Iowa Model.

Model Use/reprinted with permission from University of Iowa Hospitals and Clinics, Copyright 1998. For permission to use or reproduce please contact the university of Iowa Hospitals and Clinics at 319-384-9098

An example of this process can be seen with the implementation of the Chlorhexidine Gluconate (CHG) 2% oral rinse in the critical care division. In 2010, an occurrence of a ventilator-acquired pneumonia (VAP) led Vicki DeChirico RN, MSN, CIC, Infection Control Coordinator to consider the use of CHG oral rinse on patients who are on mechanical ventilation. A team was formed comprised of the critical care Nurse Manager, Clinical Nurse Leaders, Educator, Staff RN, and Critical Care Intensivists. The team evaluated the recent literature and found several research studies including a systematic review, demonstrating the benefit of CHG 2% oral rinse in the prevention of VAP. The oral care products used in the critical care units were upgraded to include the CHG oral rinse. In-services were provided to the staff regarding the new product and the evidence based practice change was implemented. The nurses in the critical care unit were asked to evaluate the use of the product and positive feedback led to the addition of CHG to the VAP prevention bundle. Vickie DeChirico continued to monitor and collect data on the incidents of VAP. Six months of data revealed no further incidences of VAP cases in 2010.

VAP Cases JCMC 2010

In 2011, the pulmonary units also adopted the use of the rinse. Outcomes from the use of the products were presented to the Critical Care Committee, Professional Practice Council and the Quality and Safety Nursing Council. The oral policy was updated to include the use of the CHG oral rinse on all ventilated patients (Appendix NK7-B Oral Care Policy). Today the use of the oral rinse is part of the critical care nurses standard of practice.

Critical Care Team Established to Review Practice Change Based on Evidence

NK7-Table 1

Participation in National and State Initiatives

Another process used to translate new knowledge into practice is through participation in state, and national initiatives. Participation in these initiatives encourages staff nurses and nursing leaders to advocate and promote change based on evidence. In embracing a culture of safety, JCMC and has joined many collaboratives and has participated in various national quality initiatives. This has allowed best practice protocols to be fleshed out throughout units such medical surgical, critical care, perinatal and perioperative services. Key performance indicators measured as a result of participation in state and national initiatives can be seen in JCMC 2011 score card (NK7-C 2011 score card).

Initiatives JCMC has participated in include:

  • New Jersey Hospital Association (NJHA)
    • Perinatal consortium
    • Sepsis Collaborative
    • Partnership for Patients
    • ICU collaboratives:
      • VAP bundles
      • Central Line Associated Blood Stream Infection (CLABSI) prevention bundles
    • Antimicrobial Resistance (AR) Collaborative
  • Institute for Healthcare Improvement (IHI)
    • Preventing CHF readmissions
    • Transforming Care At the Bedside (TCAB)
  • National Database of Nursing Quality Indicators
    • Pressure Ulcer Collaborative
    • Falls prevention Collaborative
    • Reducing Restraint Use
  • American Hospital Association (AHA)/ Health Research and Education Trust (HRET)
    • On the Cusp – CAUTI

Implementation of the Catheter Associated Urinary Tract Infection (CAUTI) bundles is a great example of how new knowledge was translated into practice through nursing involvement in national and statewide collaboratives. Participation in the NJHA Antimicrobial Resistance (AR) collaborative, since its initiation in 2005, has led to increased awareness and ongoing implementation of the CAUTI evidence based protocols or “bundles” in the critical care units. Successful implementation of the CAUTI bundles generated positive outcomes and led to the role out of these bundles on the medical surgical units in 2011. Successful Evidence based practices implemented and currently ongoing include:

“Bundles” pocket card developed by Vickie DeCherico BSN, RN.
 “Bundles” pocket card developed by Vickie DeCherico BSN, RN.  
  • Daily assessment for indication of the catheter
  • Assessment and communication regarding the need for urinary catheter daily with multidisciplinary team during rounding
  • Ongoing education on catheter use and CAUTI bundles
  • Purchase and implementation of standardized catheter securement device
  • Frequent monitoring to maintain the drainage bag lower than the level of the bladder and the tubing above the level of the bag
  • Nursing staff discontinues catheter as soon as possible and reason for continuation of catheter use is documented in medical record daily.

The NJHA AR collaborative provided evidence based resources and networking opportunities to enhance the implementation of these practices. In addition, ongoing data collection and benchmarking through the National Healthcare Safety Network (NJSNA) assists in trending patient outcomes and benchmarking against other similar facilities nationwide. In efforts to continuously improve patient outcomes and maintain CAUTI rates below the national benchmark, opportunities to continue on this journey were explored. In 2012, the “On the CUSP – Stop CAUTI” methodology (Appendix NK7-D) was implemented on 7W medical surgical unit to further strengthen the process of CAUTI prevention.

RNs are updated regularly on recent finding regarding these best practices through unit based educational sessions provided by the infection control nurses Vickie DeChirico MSN RN, CIC and Mary Ann Plaskon BSN, RN, CIC. In addition, Clinical Ladder nurses have assumed the role as champions on individual nursing Units. This ensures a clinical resource is available on each unit that is knowledgeable and reinforces the use of the “bundles”.

NK7-Table 2

Successful implementation of these evidence-based practices in medical surgical and critical care units prompted administration to include CAUTI best practice bundles in the 2012 Strategic Plan. In addition, JCMC enrolled in the NJHA Partner for Patients to ensure continued success with this initiative

CAUTI 2010 Rates

CAUTI 2010 Rates

CAUTI 2011 Rates

CAUTI 2011 Rates

Translation of New Knowledge by Nursing Leaders

Clinical Educators, Clinical Nurse Leaders, and Clinical Coordinators commonly translate new knowledge into practice. They are available to the staff via email, phone, and daily rounding. They frequently seek out opportunities such as attending conferences, performing reviews of literature on identified needs, and participate in national and statewide initiatives as previously mentioned.

A process in which the educators translate new knowledge into practice is through the learning management system “Elsevier/MC strategies”. This system provides evidence-based educational activities and clinical information offered to the staff nurses via an electronic platform accessible 24 hours a day seven days a week. In addition to the many evidence-based competencies available, written modules developed by the educators using relevant research findings are uploaded yearly. For example annual competencies on Central line Associated infections (CLABSI), Ventilator Associated Pneumonia (VAP) prevention and Catheter Associated Urinary Tract Infection (CAUTI) are available via MC strategies. A discussion board feature is also available. A goal for 2013 is to use these discussion boards to further assist in translating new knowledge into practice.

Translation of New Knowledge by Nursing Leaders

Another example of new knowledge translated into practice can be seen in the implementation of a new fall risk assessment tool and improved intervention based on the assessment scores. Peggy Petrucelli BSN, RN, Falls Coordinator, Winnie Cherubin, MSN, RN, CNL, Janice Kozzi, MSN, RN, CNL and Krystyn Rotolo CNL student from Seton hall College of Nursing, did an extensive literature review to determine the best approach to accurately identify patients at risk for falls, with the goal of implementing an institution specific fall risk assessment tool.

Number of Falls on Medical Surgical and Critical Care Units

An increase in the number of falls in 2011 prompted an evaluation of the strategies used by nursing staff to prevent falls. Initially, the JCMC falls prevention program consisted of the Hendricks II falls assessment tool, yellow identification wristband for patient identified at falls risks, safety huddles, frequent rounding by RNs and PCTs, and a yellow “falling star” identification placed outside the patients room. An ongoing review of all incidents of falls by Peggy Petrucelli revealed the problem was two fold:

  • A population of patients existed who were inaccurately identified
  • A population of patient existed who were not identified as a fall risk but were falling.

Further evaluation revealed that the patients falling at JCMC comprised of males between the ages of 40 to 50 years in age. The Hendirch II was not meeting the needs of the institution and was inaccurately identifying the population at risk at JCMC. Therefore, a need to change to a new fall risk assessment tool was identified by the team. In addition, an extensive review of the literature was completed on current and new measures to reduce falls.

At JCMC, nurses play a pivotal role in the prevention of falls. A series of tools are available in the literature when assessing falls risk. The Johns Hopkins Falls Assessment tool was selected because it was developed at John Hopkins using an evidence based approach and includes seven risk factors significantly associated with falls.

In addition to conducting a review of the literature, Kristen Rotolo CNL student from Seton Hall, conducted a brief evaluation of ten patients using both the Hendrich II Fall risk assessment and the John Hopkins Fall Risk Assessment to evaluate the use of the tool on the JCMC patient population. Ten Random patients were selected on a medical surgical floor at JCMC. Kristen Rotolo performed a physical assessment and chart review, and completed both the Hendrich II and the John Hopkins Fall risk assessment on each patient. A comparison of results revealed:

  • Three patients identified as high risk patients according to John Hopkins and not identified as a fall risk according to Hendrich II
  • Two were identified as moderate risk by John Hopkins model compared to low risk score using Hendrich II
  • Three patients were identified as low/no risk according to John Hopkins compared to a high risk assessment using Hendrich II
  • One patient was identified as a high risk according to Hendrich II, however because the patient was a quadriplegic the John Hopkins tool identified patient as low risk
Peggy Petrucelli BSN, RN, Falls Program Coordinator
 Peggy Petrucelli BSN, RN, Falls Program Coordinator  

An additional chart review was performed by Peggy Petrucelli BSN, RN on all patients who fell between May to June 2011. A secondary assessment was completed using the John Hopkins Risk Assessment and compared to the Hendrich II Assessment documented by the primary nurse. A review of the literature and an evaluation of the data presented, led the team to consider the John Hopkins assessment as a more precise tool when evaluating the patient population at JCMC. The tool was presented and approved by the Interdisciplinary Falls Prevention Team and Professional Practice Committee. Permission to adopt the tool at JCMC was obtained and evidence based measures to reduce fall were implemented based on a two tier system. The protocol was developed and launched via the new Sorian electronic medical record system on July 24th 2012. For detailed information regarding fall prevention methods based on John Hopkins scoring system please refer to the Falls Prevention Policy (Reference NK7-A Fall Prevention Policy). Below is a screen shot of the John Hopkins Fall Risk Assessment in the electronic medical record.

John Hopkins Falls Assessment Sale

John Hopkins Falls Assessment Sale
Copyright (C) 2007 by The Johns Hopkins Health System Corporation.
All rights reserved

All information contained in this document is provided “as is” with no representations or warranties whatsoever. No part of this work may be modified, redistributed or reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without the prior written permission of Johns Hopkins

Slide provided by Peggy Petrucelli, BSN, RN. It was used during education provided to nurse on all medical surgical units
 Slide provided by Peggy Petrucelli, BSN, RN. It was used during education provided to nurse on all medical surgical units  

Prior to house wide implementation of the protocol, education was provided to all nursing staff (Appendix NK7-E) regarding:

  • The evidence based process used to revise the existing protocol
  • Nursing documentation requirements launched with the new electronic medical record
  • Proper use of new tool,
  • Evidence based falls prevention strategies based on fall risk level.

Nurses also embraced this new process by holding a falls summit on the 6W and 7W medical surgical units, adopting the theme “Will not fall …Not on My Watch”. Please refer to (Appendix NK7-G) for a sample sign in sheets of the event.

After implementation on July 24, Peggy continues to assess and collect data on the effectiveness of the fall screening system and the interventions applied to patients identified at risk. The ongoing evaluation of the process along with staff input revealed opportunities for improvement such as reorganizing the EMR screen for clearer understanding by staff nurses. Peggy and the falls reduction committee will continue actively seek other opportunities for improvement to ensure successful implementation of this new evidence based protocol.

John Hopkins Falls Assessment Sale

Knowledge Translation of Nursing Policies and Procedures

Every two years, policies are updated and reviewed to reflect the current evidence-based practices. Nursing policies and procedures go through many different levels of review to ensure that they are based on new knowledge. All nursing policies must be presented and approved by the Professional Practice Council prior to final submission to the policy Committee. Members of the Professional Practice Council review each policy to determine whether or not it is based on relevant evidence and consistent with nursing standards of practice. Any policies relating to quality of care and patient safety must also be submitted to the Quality and Safety Nursing Council for approval. This council evaluates the policy and the related literature making certain it is translated in manner that promotes quality and patient safety. After approval through the Nursing Councils the policy is presented to the policy committee for final review. This committee ensures that the policy include appropriate references that are no older then 5 years. Once approved by the policy committee, the policy is signed and put into effect. Council members will assist in disseminating the policy and related evidence to their Unit Practice Councils.

Dissemination of New Knowledge

Nurses at all levels have participated in many poster and podium presentations to assist others in translating new knowledge into practice. Please refer to Reference SE2-A for a complete list of presentation provided by nurses at JCMC.