SE - Structural Empowerment

SE2EO: Professional Engagement-Describe and demonstrate two improvements in different practice settings that occurred because of nurse involvement in a professional organization(s).

Improvement in the operating room related to nurse involvement in professional

Issues frequently arise relating to the sterilization of instrument trays in the operating room. As a result of rising operating room specialty procedures, for example open heart and dental procedures, more instruments need to be purchased in order to be able to process the instrumentation in a timely and correct manner.

Total Number of Open Heart and Maxillofacial Procedures


SE2EO-Table 1


SE2EO-Table 2

Each sub-sterile area (the area between every two operating rooms) contains a sterilizer that may be used for immediate use items. Flashing of instrumentation refers to a method of sterilization that differs from the usual methodology. The usual method for sterilization is either a wrapped instrument tray or a closed instrument container which is sterilized for thirty minutes at 250 degrees Fahrenheit and a 15-30 minute dry cycle. In the Flash Sterilization technique, however, the instruments are placed in a “flash” tray and are sterilized for 3-10 minutes at 270 degrees Fahrenheit without a drying cycle. The fear with this sterilization process is the risk of increased infection to patients because of pressure on personnel to eliminate one or more steps in the cleaning and sterilization process.

The rationale for flashing instruments varies. On occasion, an essential instrument may fall from the sterile field and may need to be sterilized for immediate use. Other issues which may arise and lead to flashing of instrumentation may be the lack of sufficient instrumentation to perform certain procedures. This is the problem that needs to be addressed.

The Association of Operating Room Nurses has identified in their Standards of Practice (2011) the parameters necessary to sterilize instruments for immediate use. The standard states: Use of flash sterilization should be kept to a minimum. Flash Sterilization should be used only in selected clinical situations and in a controlled manner. Sennen Cabalfin BSN, RN staff nurse in the operating room, and Vickki Ebanks MSN, RN, CNOR Nurse Educator in the operating room were concerned about the high numbers of flash sterilization that had been occurring and determined to improve this process and therefore be in compliance with the standard. Members of this Performance Improvement team included the following:

SE2EO-Table 3

The team determined that a multifaceted approach would be utilized. They began with educational sessions conducted by Ms. Ebanks which focused on the issue of overall instrument sterilization which incorporated the flashing of instrumentation (Appendix SE2EO-A). The Staff members are required to list the item flashed on the sterilizer generated receipt as well as sign their names. Ms. McLaughlin tracked and trended the data based on the sterilizer print-outs and prepared a monthly report (SE2EO-B) with each sterilizer identified by number. Ms. McLaughlin would present that report at the monthly staff meeting. The reason why something was flashed was also listed on the sterilizer receipt. This information was useful in informing the team what items needed to be ordered to avoid the continued flashing of instruments. Alan Warshawski would then place an order for necessary items.

The results of the team’s efforts were beneficial. They were able to significantly reduce the incidents of flash sterilization. They reduced the incidents in each month with the exception of March, 2012. Sterilizer number three was between the open heart rooms and they had 23 procedures that month, the most that the organization has ever had. We did remedy the situation by ordering new instruments and retractors.

Jersey City Medical Center Immediate Used Audit

Cardiothoracic Nurses involvement in the modification of nurse driven insulin drip protocol to meet SCIP requirements

The Surgical Care Improvement Project (SCIP) mandates that cardiac surgery patients maintain a glucose level less than 200mg/dl on 6am on postoperative days (POD) 1 and 2. This is recommended to decrease post operative infections such as surgical site infections. In January of 2011, a new insulin protocol was implemented in the critical care division. During this transition an unexpected decrease in compliance occurred during the first quarter of 2011. On two occasions blood glucose levels failed to maintain below 200mg/dl decreasing compliance rates to 96.8%. This led the cardiothoracic nursing staff and nursing leadership to initiate a plan and strategize ways to improve the newly developed insulin drip protocol. Nicole Sardinas MSN, RN, CCRN, and Sandy Liu Pharm D. organized a team of nurses, to evaluate the process and develop a plan to further prevent glucose levels of greater than 200mg/dL on postoperative day 1 and 2.

Cardiothoracic Nursing Team

SE2EO-Table 4

All the staff nurses involved in the team are long standing members of the American Association of Critical Care Nurses. They were all aware of how important this measure was to the safety of post operative cardiothoracic patients. The team reviewed recommendations of best practices endorsed by the AACN to identify opportunities for improvement. Using the AACN recommendation, a review of the current processes was completed. This review identified a need for tighter blood glucose control and improved transition process from insulin drip to sliding scale. A plan was devised by team for prompt intervention and improved glucose management. The new insulin drip protocol was modified to meet the recommended blood glucose goal for cardiothoracic patient as recommended by SCIP and to provide better control for patients with insulin resistance.

SE2EO-Table 5

Maikel Herrera BSN,  Mayling Reyes BSN, RN, Natasha Gangasarran BSN,  RN,  Diana Kirschenbaum BSN, RN, CCRN Arlene Ramos BSN, RN
Maikel Herrera BSN, Mayling Reyes BSN, RN, Natasha Gangasarran BSN, RN, Diana Kirschenbaum BSN, RN, CCRN Arlene Ramos BSN, RN

The recommended changes were discussed at the UPC. The open heart nurses working on the night shift were instrumental in trialing the process and providing feedback. Changes were made based on their recommendation to the insulin drip and the supplemental insulin scale order forms. The medication administration records forms.

One quarter after initiation of the revised protocol, compliance increased to 100%. Success of this change was contributed to the involvement of all the cardiothoracic nurses working in the CCU. This change has successfully sustained improvement with 100% compliance during the last eight quarters.

SCIP-Inf-4 Cardiac Surgery Patients with controlled 6AM postoperative serum glucose