Session Number 211

“LET’S BE THE DRIVER OF THIS BUS:” NURSE DRIVEN PROTOCOLS IN ACUTE CARE

Donna Barto, DNP RN CCRN

Advanced Nurse Clinician Virtua Health

Marlton, New Jersey

Content Description This presentation reviews the need for the use of more nurse driven protocols in the acute care setting as well as briefly looks at several protocols that are already in existence. The process of putting together a nurse driven protocol will be reviewed as well as the barriers faced when initiating this change in practice. Ways to improve compliance with the utilization of the protocol as well as monitoring its outcome will also be discussed. Learning Objectives At the end of this session, the participant will be able to: 1. Identify the reasons for utilizing a nurse driven protocol. 2. Review current nursing protocols being utilized in the acute care setting 3. Discuss the steps needed to implement a nurse driven protocol in the clinical setting. Outline (see power point slides) A. Purposes of nurse driven protocols B. Examples of protocols currently in use in the acute care setting C. How to identify the need for a protocol on your unit D. Development of the protocol E. Implementation of the protocol F. Sustaining the change References

1. Bair H, Ivascu F, Janczyk R, Nittis T, Bendick P, Howells G. Nurse driven protocol for head injured patients on warfarin. Journal of Trauma Nursing. 2005; 12(4): 120-126. 2. Beck L, Johnson C. Implementation of a nurse-driven sedation protocol in the ICU. The Journal of the Critical Care Association of Canadian Nurses. 2008; 19(4): 24-28. 3. DeWit M, Gennings C, Jenvey W, Epstein S. Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients. http://ccforum.com/content/12/3/R70. 4. Grap M, Strickland D, Tormey L, Keane K, Lubin S, Emerson J, Winfield S, Dalby P, Townes R, Sessier C. Collaborative Practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care. 2003; 12: 454-460.

5. Gray M. Reducing catheter-associated urinary tract infection in the critical care unit. AACN Advanced Critical Care. 2010; 21(3): 247-257. 6. Heyland D, Cahill N, Dhaliwal R, Sun X, Day A, McClave S. Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. Journal of Parenteral and Enteral Nutrition. 2010; 34(6): 675-684. 7. Jarachovic M, Mason M, Kerber K, McNett M. The role of standardized protocols in unplanned extubations in a medical intensive care unit. American Journal of Critical Care. 2011; 20(4): 304-311. 8. Kanji Z, Jung K. Evaluation of an electrolyte replacement protocol in an adult intensive care unit: a retrospective before and after analysis. Intensive and Critical Care Nursing. 2009; 25: 181-189. 9. Manojlovich M. Predictors of professional nursing practice behaviors in hospital settings. Nursing Research. 2005; 54(1): 41-47. 10. Plost G, Nelson D. Empowering critical care nurses to improve compliance with protocols in the intensive care unit. American Journal of Critical Care. 2007; 16(2): 153-157. 11. Van Halen R, Van Vuuren H, Van Domburg R, Van der Woerd D, Hofland J, Bogers A. Pain management after cardiac surgery: experience with a nurse-driven pain protocol. European Journal of Cardiovascular Nursing. 2012; http://cnu.sagepub.com/content/early/2012/01/04/1474515111430879. 12. Weinert C, Mann H. The science of implementation: changing the practice of critical care. Current Opinions in Critical Care. 2008; 14: 460-465.

Speaker Contact: dbarto@virtua.org

DONNA BARTO, DNP, RN, CCRN

NO FINANCIAL DISCLOSURES

LET’S BE THE DRIVER OF THIS BUS – NURSE DRIVEN

PROTOCOLS IN ACUTE CARE

OBJECTIVES

Identify the reasons for utilizing a nurse driven protocol

Review current nursing protocols being utilized in the critical care setting

Discuss the steps needed to implement a nurse driven protocol in the clinical setting

It is 2 AM; your patient has a temperature of 101.

NURSE DRIVEN PROTOCOL

ADVANTAGES OF NURSE DRIVEN PROTOCOL

They have been shown to improve patient care outcomes and contain cost

Staff nurses have identified “success” as being able to give their patients quality care

Quality care leads to nursing job satisfaction

Nursing empowerment

Healthy work environment (increased retention rates, increased patient satisfaction)

THE PROBLEM IN SOUTHEASTERN MICHIGAN

Several elderly, anticoagulated patients with minor head injuries rapidly deteriorated and died

48% mortality rate in warfarin anticoagulated patients compared to a 10% in non-anticoagulated patients

Coumadin protocol initiated

Bair, H. et al. (2005) Nurse Driven Protocol for Head Injured Patients on Warfarin. Journal of Trauma Nursing, 12(4), 1.20-126.

PATIENT ON COUMADIN PROTOCOL

Nurse notifies ECP to evaluate

Nurse calls blood bank for T&C and FFP

Nurse arranges for CAT scan

Positive CT Negative CT

Transfuse FFP Admit patient

Give Vitamin K

Stat neurosurgery consult

OUTCOMES OF COUMADIN PROTOCOL

PRE-PROTOCOL

MD initial evaluation 31 minutes

Time to CT scan 2 hours

Mortality 48%

POST-PROTOCOL

MD initial evaluation 15 minutes

Time to CT scan 40 minutes

Mortality 10%

WEANING PROTOCOL

Used to wean patients from mechanical ventilation in a medical respiratory unit

Combined nurse driven/respiratory therapyprotocol

Outcomes: reduced duration of mechanical ventilation as measured by ventilator days

Downward trend in the stay of intensive care unit from a mean of 8.6 days to 7.9 days (p=0.7)

Grap, M. et al. (2003 ) Collaborative practice: Development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. American Journal of Critical Care, 12: 454 – 460.

SCREEN 1

1. Hemodynamics stable?

2.Off vasopressors

3.PaO2/FIO2 ratio > 150

(If ABG’s not available, SaO2> 95% on 50% or less)

4.PEEP set at 8 cm H2O or less?

5. RASS of -2 or higher?

If NO to any questions, STOP!

Otherwise, ALWAYS proceed to screen 2

SCREEN 2

Rapid Shallow Breathing Index (RSBI).

RSBI of 125 or less?

If YES, proceed to spontaneous breathing trail. If NO, rest patient until the next day and reassess starting with screen 1.

• Spontaneous breathing trial:

Criteria such as heart rate, blood pressure, respiratory rate taken on a two hour continuous trial. If spontaneous breathing trial is passed, patient is extubated.

UNMEASURED SUCCESS

Discussions with nursing staff indicated that the use of the protocol has increased nursing’s sense of autonomy

Increased their direct involvement in decisions related to patients’ care

Provided an additional avenue for communication with the healthcare team

Increased their knowledge of respiratory assessment and mechanics

NURSE DRIVEN SEDATION PROTOCOL

Implemented in a Canadian hospital in June 2006

Had four pathways: pain, anxiety, delirium and neuromuscular blockade

Pain and anxiety were one order sheet

Delirium and neuromuscular were separate order sheets

Utilized the Richmond Agitation Sedation scale, the visual Analogue scale, and the Confusion Assessment method-ICU Delirium Tool to determine how to dose medications

REASONS FOR STARTING PROTOCOL

Differences in physician practice, variety of pharmacologic agents, nurse’s level of expertise, personal preferences makes managing anxiety, pain and delirium an ongoing challenge

Wanted to help the critical care nurses make decisions that promote positive outcomes for patients receiving sedation and analgesia

Beck, Lisa, Johnson, C. (2008). Implementation of a nurse-driven sedation protocol in the ICU. Dynamics. 19 (4). 25 – 28.

OUTCOMES

Descriptive study of 75 nurse

Looked at the perceived benefits of implementing the protocol in terms of medication errors and staff perceptions

No medication errors or near misses reported throughout implementation

Staff perceived an improvement in the quality of care when using the protocol

ELECTROLYTE REPLACEMENT PROTOCOL

Initiated in an intensive care unit in Canada in 2007

Started in response to different physicians prescribing practices that led to inadequate replacement, less timely administration of electrolyte replacement, and the evidence that showed that protocol driven interventions are associated with improved outcomes

Pre-printed order form from which ICU nurses can administer replacement doses of potassium, magnesium and phosphate

PURPOSE OF THE STUDY ON THE PROTOCOL

Is this protocol effective by providing timely replacement of electrolytes?

Are nurses and physicians satisfied with the electrolyte replacement protocol?

Retrospective chart review and nursing/physician survey conducted

OUTCOMES OF ELECTROLYTE PROTOCOL

Number of replacement doses indicated but not given was reduced for magnesium from 60% to 35% (p=0.18) and for phosphate from 100 % to 64 (p= 0.04)

Time to replace potassium and magnesium decreased

Nurses and physicians were satisfied with the electrolyte protocol

Kanji, Z. and Jung, K. (2009). Evaluation of an Electrolyte Replacement Protocol in an adult Intensive Care Unit: A retrospective before and after analysis. Intensive and Critical Care Nursing, 25:, 181 –189.

NURSE DRIVEN PROTOCOL FOR PAIN MANAGEMENT

Used in a step down unit in the Netherland In 2008, improvement areas were identified for the

hospital A total of 34% of all pain measurements were found

to be above an acceptable upper level for pain 60% of this group still scored above this upper level

eight hours later Task force started consisting of anesthesiologists,

cardio-thoracic surgery, nurse practitioner, intensive care unit nurse, hospital safety officer rewrote the pain protocol

PAIN PROTOCOL

Allowed nurses to administer analgesic medications without consulting the attending physician

Utilizes acetaminophen and Morphine based on the patient’s Visual Analog Score and other parameters

Saw a reduction in VAS scores as well as a reduction in time to achieve an acceptable pain score with the protocol

Van Valen et al. (2012). Pain management after cardiac surgery: experience with a nurse-driven pain protocol. European Journal of Cardiovascular Nursing, 0 (0): 1 – 8.

PAIN PROTOCOL

Starts when patient arrives in step down If vital signs are stable, and VAS reveals pain, Tylenol is

given VAS score repeated 60 minutes Depending on VAS score, patient is observed, given

morphine (sc), or physician is consulted Ramsay score is also carried out to make sure patient is

not over sedated No greater than 0.2 mg/kg morphine is given per shift

without consulting MD/nurse practitioner(200 lb man = no more than 18 mg morphine)

ENTERAL FEEDING PROTOCOL

2010 study carried out to evaluate the effect of enteral feeding protocols on key indicators of enteral nutrition in critical care areas

International in scope, two year observational study

269 intensive care units

Compared sites that did not use a feeding protocol with those that did

Findings: Sites using protocol used more enteral nutrition alone, started enteral feedings sooner, caloric requirements attained were higher

CONCLUSIONS OF ENTERAL PROTOCOL STUDY

“Presence of an enteral feeding protocol is associated with significant improvements in nutrition practice compared with sites that do not use such a protocol”

Heyland, D. et al. (2010). Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. Journal of Parenteral and Enteral Nutrition. 34: 675

NURSE-LED ENTERAL FEEDING ALGORITHM

22 bed intensive care unit in London

Algorithm was designed to enable nurses to initiate enteral feeding as well as set the calorie target rate based on the patient’s body weight

Established that the gastric residual should be not greater than 200 mL

Residuals are checked every 4 hours until target; then q 8 hours

Discard all aspirates

ENTERAL PROTOCOL

If three consecutive aspirates are greater than 200 mL, nurse can give metoclopramide

Algorithm allows for dietician referral

There are patient specific criteria for not starting enteral feedings (e.g. bowel resection, unable to insert NG tube)

Dobson, K and Scott, A. (2007) Review of ICU nutrition

Support practices: implementing the nurse led

Enteral feeding algorithm. British Association of

Critical Care Nurses. 12 (3)

Performance indicators for your unit

Hand washing

HCAPS scores

Look at “never” events

Catheter associated urinary tract infections(CAUTI)

Central Line Blood Stream Infections (CLABSI)

Ventilator Associated Pneumonia (VAP)

Pressure ulcers

Surgical site infections

What Protocol?

Look at the evidence supporting nurse-implemented protocols

Sedation /analgesia

Ventilator Management

Delirium

Early Mobility

Balas, M. et al. (2012). Critical Care Nurses’ Role in Implementing the “ABCDE Bundle” into practice. Critical Care Nurse, 32: 35 – 47.

MOST IMPORTANT

CAUTI PROTOCOL

Most common hospital acquired infectionCost ranges from $1,200 to more than $2,700 per

caseResponsible for 13% of nearly 100,000 HAI deathsWill no longer be reimbursed by CMSValue Based purchasing incentivesOur unit had CAUTI’s

Use your medical librarian to do searches or to teach the staff how to do literature searches

Use the evidence gathered by specialty practice organizations (AACN) aacn.org

Query other organizations

Use the strongest evidence

LEVELS OF EVIDENCE(John Hopkins)

LEVEL Imeta-analysis of randomized control trialsrandomized control trial

LEVEL 2Quasi-experimental study (not randomized)

LEVEL 3Non-experimental study (descriptive, comparative,

relational)Qualitative study (interview, focus group,

observations)

Make sure corporate level is on board with the protocol and can provide the necessary support

Select a multidisciplinary team

Create “buy in” from those involved

Communicate, communicate, communicate

FOLEY REMOVAL PROTOCOL

Nurse to assess daily with the following exceptions: o Foley removal date already ordered o Order to reinsert or maintain foley for medical necessity present within the last

two days o Foley is a chronic foley o Patient will be discharged with foley o Patient has CBI ordered o End of life (palliative) care for terminal illness

YES

Order to “maintain foley for medical necessity” must be

written or entered into CPOE

Notify physician to determine if foley catheter

remains medically necessary

Order received to discontinue foley

NO

Does the Patient Have Any of the Following:

Physician order to re-insert or maintain catheter for medical necessity that was ordered >2 days ago

S/P GU/GYN Surgery Urology consulted Patients Urinary Tract Obstruction Urinary Catheter placed by urologist Gross Hematuria in pts with clots/irrigation Neurogenic Bladder Dysfunction Urinary retention not manageable by other

means (intermittent catheterization) Stage 3 or 4 Pressure Ulcer in an

incontinent patient Need for Strict I&O measurement Ventilator/sedation<2 days post-op ARF: ↑creatnine and/or ↓urine output

Discontinue Foley

Spontaneously voids in 6-8 hours> 250cc, continue to monitor as clinically appropriate

Spontaneously voids in 6-8hrs < 250cc, perform bladder scan, if PVR is > 250cc, initiate Straight Cath (SC)

Spontaneously voids in 6-8hrs but INCONTINENT Perform bladder scan, If PVR is > 250cc, initiate Straight cath. If PVR is < 250cc, promote personal care

No void 6-8hrs or uncomfortable at ANYTIME, perform bladder scan. If total bladder volume <400 monitor as appropriate for spontaneous void. If total bladder volume is ≥400cc initiate Straight Cath

Reassess patient and notify Licensed Independent Practitioner as clinically

appropriate Revised 12/1/11

Protocol from Virtua Health System, 2012

LEWIN’S CHANGE THEORY

Kurt Lewin(1890 – 19470) is the originator of change theory

Also wrote on group dynamics

Interested in investigating the conditions and forces which bring about change or resist change in groups

UNFREEZE CHANGE REFREEZE

Educate all involved with the new protocol

Formal classes

on-line educational program

“TRIP” sheets posted

Unit based council meetings

Use bulletin boards

Have it be placed as the computer background

Utilize a “buddy system”

DRIVING AND RESTRAINING FORCES

MAY THE FORCE BE WITH YOU

DRIVING FORCES

Presence of change champions

Staff training, education and problem solving related to the guidelines

Strong unit or organizational leadership

Collaboration with multidisciplinary teams

Ploeg, J. et al. (2007). Factors Influencing best-practice guideline implementation: lessons learned from administrators, nursing staff, and project leaders. Worldviews on Evidence-Based Nursing, Fourth Quarter 2007.

RESTRAINING FORCES

Staff time

Workload and resource constraint

Lack of access to equipment and resources

Staff resistance to change

BARRIERS TO USE OF SEDATION PROTOCOLS

No physician order Lack of nursing support Fear of over sedation Concern about risk of patient initiated device

removal Inducement of respiratory compromise or patient

discomfort

Tanios, M. et al. (2009). Perceived barriers to the use of sedation protocols and daily sedation interruption: A multidisciplinary survey. Journal of Critical Care. 24: 66 – 73.

Monitor compliance with outcome

Discuss during multi disciplinary rounds

Share data of patient outcomes with staff

Education “blitzes”

Make education about the protocol part of orientation to the unit

Celebrate the success of the protocol

EXTRINSIC REWARDS TO INCREASE COMPLIANCE

Study done in Tulsa, Oklahoma A total of 35 beds in several intensive care units Sampling of 9 protocols (vent weaning, DVT

prophylaxis, Enteral nutrition, insulin drip, insulin sliding scale, sedation/analgesia, skin care, stress ulcer prophylaxes, rotation therapy

Observation indicated protocols were not being used consistently by physicians

Plost, G., and Nelson, D. (2007). Empowering critical care nurses to improve compliance with protocols in the intensive care unit. American Journal of Critical Care: 16 (2)153-156.

EXTRINSIC REWARDS

Each staff member of any adult ICU with a 90% compliance rate for 9 selected protocols after four months received an award

Rewards consisted of catered dinner party for the ICU staff, drawings at the party for individual rewards such as personal digital assistants, gift certificates, scrubs and a grand prize of a continuing educational trip valued at $3,000.

Protocol compliance rates increased from 62% to 99%