Notable Nursing. Adopting a Patient-Centered Medical Home Model of Care p. 01. The Stanley Shalom Zielony Institute for Nursing Excellence

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1 Feature Stories ICU Immersion Program Prepares Nurses p. 05 Dedicated Educational Unit Program Focuses on Closing Practice Gap p. 08 Nursing Leads Innovation Program p. 12 Also Inside Best Practices pp. 11, 15 Research pp. 16, 17 Notable Nursing Spring 2014 A Publication for Nurses by Nurses The Stanley Shalom Zielony Institute for Nursing Excellence Cover Story Adopting a Patient-Centered Medical Home Model of Care p. 01

2 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable 2 Table of Contents Feature Articles p. 01 Patients Take Center Stage: New Patient-Centered Medical Homes Empower Patients and Nurses p. 03 Quality Improvement Initiatives Yield Results p. 05 ICU Immersion Program Eases New Nurses Toward Optimal Bedside Care p. 08 Dedicated Educational Unit Program Focuses on Closing Practice Gap During Clinicals p. 12 Initiating Innovation: Systemwide Program Puts Nurses at the Forefront of Trialing New Ideas, Technologies and Processes Best Practices p. 11 Having a Co-Charge Nurse Ensures Better Patient Safety p. 15 Oncology Infusion Team s New Program Engages Nurses, Improves Patient Compliance and Satisfaction Research p. 16 Factors Associated with Chest Tube Management Time p. 17 Improving Nurse Certification Rates Back Page Awards Dear Colleagues and Friends, I am delighted to welcome you to our spring 2014 edition of Notable Nursing. Innovation is our theme this month as we push forward in testing and implementing some exciting new practices in The Stanley Shalom Zielony Institute for Nursing Excellence. The changing landscape of healthcare has been altered by full implementation of the Affordable Care Act. In an effort to be ready, Cleveland Clinic is piloting a patient-centered medical home (PCMH) model of care. The PCMH model brings a comprehensive approach to caring for patients with chronic diseases. Integrated care is enhanced, changing the way nurses practice in a fundamental way. The PCMH model streamlines care and allows nurses to practice at the top of their licenses. Learn more in our cover story. In other news, our Ideas 2 Innovation (I2I) program invites nurses throughout the institute to bring clinical practice ideas forward for consideration. We ve created a living laboratory across the enterprise to explore new approaches to care. As ideas are submitted, they will be vetted by an I2I nursing council and when approved, they will be evaluated for feasibility, benefits, efficiency and other factors important to nursing practice and patient care. In some cases, a formal research trial may also be completed. Our goal is to implement one novel approach/technique/device/informatics innovation or process each quarter throughout the year. Read more on page 12. In the area of nursing education, two approaches to training new nurses are being examined. We are turning a traditional nursing student model on its head as we explore the Dedicated Educational Unit (DEU) program, which provides immersive training by frontline staff nurses during students clinical experiences. Hear what our nurse trainers and trainees have to say about this robust new training program on page 8. In addition, newly hired nurses in intensive care units can participate in the ICU Immersion Program, designed to increase confidence in assessment and evaluation of patient changes. Through a grantfunded research program, nurses can build critical thinking skills to improve clinical decision-making. Initial results look positive! See page 5. I hope this issue gives you ideas for creativity and innovation in your own setting. Please contact us to share your thoughts on our activities or to explore how we can work together to advance our vital profession. You can reach us anytime at notablenursing@ccf.org. I look forward to hearing from you. This publication is printed on paper certified to the standards of the Forest Stewardship Council TM (FSC ). K. KELLY HANCOCK, MSN, RN, NE-BC Executive Chief Nursing Officer Cleveland Clinic Health System Chief Nursing Officer, Main Campus Cleveland Clinic s Nursing Institute is known as The Stanley Shalom Zielony Institute for Nursing Excellence in recognition of Mr. Zielony s generous gifts to advance nursing education, informatics, research and clinical practice at Cleveland Clinic.

3 Notable Nursing Spring 2014 Cover Story Patients Take Center Stage Cleveland Clinic s new patient-centered medical homes empower patients and nurses, streamline appointments and improve outcomes. One of Carolyn Wright s patients is a woman in her late 50s with diabetes. She has been in and out of the hospital on separate occasions for different things, says Wright, BSN, RN, who works in internal medicine at Cleveland Clinic s main campus. But lately the revolving readmissions have tapered off, thanks in part to a team-based approach to care initiated and piloted by Cleveland Clinic s Medicine Institute starting in Three of Cleveland Clinic s primary care locations, including the internal medicine department at main campus, adopted a patient-centered medical home (PCMH) model of care. Patients have a direct relationship with a primary care physician who works in tandem with a cooperative team of healthcare professionals to provide preventive care. Teams include registered nurses and medical assistants as well as other embedded resources, such as pharmacists, diabetes educators, physical therapists and social workers. Multiple healthcare providers surround patients and manage their care, providing all medical services needed, says Jennifer D. Coleman, MSM, BSN, BSBA, RN, Clinical Nurse Manager of internal medicine and geriatrics. This team-based approach benefits patients tremendously. The diabetic woman regularly visits a pharmacist, who helps manage her insulin regimen. She calls Wright with questions, rather than heading to the emergency department, as she did in the past. If necessary, the nurse schedules a same-day appointment with the doctor or physician s assistant. Above (left to right): Monica Mugwambi, Medical Assistant; Lindy L. Nester, PA; Nancy C. Fenner, LISW-S; Carolyn Wright, BSN, RN My patient has dramatically changed her willingness and motivation to care for herself, says Wright. She relies on our team to better manage her diabetes and has improved her HbA1 c values. Providing collaborative care Ingrid Muir calls patient-centered medical homes the wave of the future. Muir, MBA, BSN, RN, is Nursing Director of Cleveland Clinic s Endocrinology & Metabolism and Medicine institutes. It s about developing trust with patients and coaching them, says Muir. You can only do that over time; not with episodic care. Care in the Cleveland Clinic PCMH begins with a report generated by the hospital s electronic medical record (EMR) system. It flags patients who have recently been hospitalized with pneumonia or myocardial infarction and those with chronic conditions, such as diabetes, kidney disease and chronic obstructive pulmonary disease. Medical assistants mail letters to identified patients, noting any lab tests or screenings that are needed prior to an appointment. During office visits, physicians and nurse care coordinators are paired and supported by the medical assistants who work together to determine if they need additional resources such as pharmacists or social workers. Patients are matched with care teams, so they see the same group of healthcare professionals. Working with one physician facilitates communication and strengthens collaboration, says Lindsey Carlisle, RN, a care coordinator in internal medicine. Nurses focus on a group of patients, rather than caring for patients of all doctors within a team. Focused relationships lead to more efficient care, she adds. 1

4 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable One Model, Three Approaches Three of Cleveland Clinic s primary care locations piloted the patient-centered medical home (PCMH) model: the internal medicine department at main campus, the Strongsville Family Health and Surgery Center and the Independence Family Health Center. Each one tweaked the model to suit its staffing and patient needs. Main Campus Each physician partners with a registered nurse, who acts as a care coordinator. The two are supported by a medical assistant and other healthcare professionals, as needed. (See article for details.) In Strongsville, Ohio Each physician teams with two medical assistants (MAs). When doctors conduct appointments, MAs enter important information electronically, freeing physicians to focus solely on patients. When physicians are done, MAs complete appointments and doctors move to another examination room, where other MAs have begun appointments with patients. Utilizing an efficient model allowed the FHC to add more daily appointments, and patients appreciate the undivided attention of physicians. In Independence, Ohio Registered nurses serving as care coordinators make weekly phone calls to patients discharged from a Cleveland Clinic facility. They ensure patients understand discharge instructions, reconcile medications and check if home care or follow-up appointments with specialists are required. 2 After office visits and hospitalizations, care coordinators also make regular follow-up calls to patients. They ask about pain levels and concerns, and review medications and the plan of care. The overall goal is to provide continuity of care and empower patients to be active participants in the healthcare process. We re trying to stop people from falling through the cracks, says Coleman. Practicing at top of license The PCMH model streamlines medical appointments and allows professionals to practice at the top of their Training Nurses to Empower Patients For the patient-centered medical home (PCMH) model to work, patients must be active participants in the healthcare process. And for that to happen, it s critical that care coordinators have more than solid clinical skills: They need communication and leadership skills, too. It s an art to empower patients and get them to do what they need to do, says Jennifer D. Coleman, MSM, BSN, BSBA, RN. Nurses need the tools to help them be successful care coordinators. At the start of the PCMH pilot, Cleveland Clinic sent five nurses to Denver for a three-day Clinical Health Coach Training Program offered by the Iowa Chronic Care Consortium. The program is an outcome-based platform that encourages patient engagement through coaching and education. The training program helped develop coaching skills, including motivational interviewing, reflective listening, readiness assessments, goal setting and engaging patients to be effective self-managers of their healthcare. Carolyn Wright, BSN, RN, attended the program. I learned how to listen to my patients, identify what is important to them and what motivates them, then try to coach them to improve their personal health goals, says Wright. Last fall, trainers from the Iowa Chronic Care Consortium presented the program to approximately 55 nurses on Cleveland Clinic s main campus. They will offer another training session on campus this spring. licenses. As an example, medical assistants bring patients to examination rooms and obtain vital signs, complete medication reconciliation and prepare the patient for the appointment. Then, nurse care coordinators consult with patients and have time to dig deeper into the current problems and other psychological, social and economic factors that can affect a patient s health status. I make sure they are up to date with immunizations and other health maintenance, but most important, I see if there are other concerns that might affect their health, says Wright. Many patients withhold or provide incomplete information when discussing their current problem. Sometimes, patients are unsure if symptoms are related to the current problem and fail to raise them as issues. I try to focus on the patient as a whole person. Patient centered medical homes provide the structure to facilitate ambulatory nurses to practice at their peak, says Muir. Care coordinators are very seasoned nurses with a lot of knowledge. Tapping their expertise and experience will be game changing. Ultimately, Cleveland Clinic hopes the PCMH model improves patient outcomes. And early indications suggest that it has. There s been a decline in readmission in the three PCMH sites compared to their peers, says Craig Martin, MPA, Quality Director of the Medicine Institute. So we are hopeful that it s having an impact. In the fall, Cleveland Clinic received the Joint Commission Primary Care Medical Home certification. This year, the PCMH model will roll out to 42 practices enterprisewide. Nurses who piloted the model believe it is worthwhile. Carlisle states, It allows me to impact chronic disease management in a comprehensive and innovative way. comments to notablenursing@ccf.org.

5 Quality Improvement Initiatives Yield Results at Cleveland Clinic Florida At Cleveland Clinic Florida, nursing is leading the way in enterprisewide quality improvement. Outcomes have improved in preventing central line-associated bloodstream infections, prevention of falls and hospital-acquired pressure ulcers. Central line-associated blood stream infections (CLABSI) Critical care nurses led a multidisciplinary group to examine ways to reduce CLABSI by applying the latest evidence-based guidelines. The group s recommendations, which began rolling out in 2010, include standardization of the carts used for central line catheter insertions so that the same equipment and processes are used at all times, says Carolyn Carter, BSHA, BSN, RN, Nursing Director of Critical Care. Nurses are offered education on central line complications to ensure systematic sharing of knowledge for everyone involved with central lines. Annually, competency checklists are used to ensure that nurses demonstrate their mastery of central line best practices, Carter says. Competencies include applying central line dressings, drawing blood from a line port and scrubbing the line hub. The bundled efforts led to real improvements in reducing CLABSI. Our incidence of hospital-acquired CLABSI in the ICU were never high, but as of 2010, we started to see a decrease, Carter says. And I am very proud to say that thanks to our quality efforts in this area, we had a three-year stretch without a CLABSI event in the ICU. Carter stresses that standardizing procedures and equipment are not enough. Continued diligence by nursing leadership is needed. For example, ICU nurse leaders include central line assessment audits during routine rounds several times a week. During rounds, nurse caregivers may be asked to explain why a patient has a central line and what actions have been initiated to reduce the need for the line. We found that most CLABSI were the result of improper central line maintenance, so we have a strong focus on ensuring best practices related to ongoing catheter dressing and line care, Carter explains. If ongoing central line monitoring is needed, the team verifies that dressings are intact, occlusive and labeled with the replacement date. Preventing falls Fall prevention is addressed at Cleveland Clinic Florida by a multidisciplinary fall prevention committee that began meeting monthly in October Many initiatives are meant to inform nurses to be more vigilant in assessing and monitoring patients who are at risk for a fall event. We put a lot of actions in place, says Raquel Bryan, RN, Nursing Quality Coordinator. We added banners that pop up in the electronic medical record to alert caregivers about high risk. Nurses were educated on and expected to give atrisk patients yellow nonskid slipper socks to wear when out of bed, and to place the high-risk status on arm bands and signs on room doors. We want all healthcare providers to know that vigilance in watching for patients who are at risk for fall events is not just a nurse issue. Physicians and others need to be aware of fall risk identifiers and how to respond, Bryan says. The hospital also acquired beds with alarms that nurses can activate as needed. If an alarm sounds, any staff member in the vicinity of the patient s room is expected to respond. Our message is, Don t wait for a nurse. It is everyone s 3

6 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable Our incidence of hospital-acquired CLABSI in the ICU were never high, but as of 2010, we started to see a decrease. And I am very proud to say that thanks to our quality efforts in this area, we had a three-year stretch without a CLABSI event in the ICU. Carolyn Carter, BSHA, BSN, RN 4 responsibility to stop and check on at-risk patients, and to call for help if necessary, Bryan explains. Along with raising awareness of at-risk patients and the addition of bed alarms, another initiative implemented is what Bryan calls the 5th P. Now, in addition to the four Ps of hourly rounding (pain, possessions, positioning and personal needs), a fifth P was added: precaution. It is a reminder for nurses to discuss safety issues with patients, such as reminding them to ask for help when needed. Ongoing messages about these fall prevention initiatives were communicated with the entire hospital staff via a safety fair and other efforts and led to an overall 20 percent drop in the number of falls in 2013 compared with 2012 data. The Intermediate Care Unit had great success with a decrease in falls by 42 percent. Knowing that fall rates never remain static, this year the committee is increasing vigilance in monitoring patients who are at risk for falls with such events as quarterly Fall Awareness Days. Hospital-acquired pressure ulcers (HAPU) Cleveland Clinic Florida took a bundled approach to improve HAPU quality. An education program was implemented on repositioning patients based on best practice guidelines. Certified wound ostomy nurse Carol Coker, ARNP, and the skin champions (skin resource nurses) educate nurses on pressure ulcer (PU) identification and staging. Nurses working in the emergency department are trained to assess patients for wounds. Community-acquired PUs are reported to physicians and admitting nurses, and documented. These actions facilitate development of a plan of care. Telemetry Unit nurse Dalia Grayeb, BSN, RN, a member of the skin and fall committees, believes nurses appreciate education and resource efforts put forward. Nurses want to develop better care plans for patients, says Grayeb. We are part of a learning environment here, not a judgmental one. We want to find the best ways to take care of patients together. Carter and Bryan agree that sharing outcomes, celebrating successes and letting everyone know they have a voice are important strategies for improving quality metrics. For example, any hospital employee is expected to speak up if they notice someone hasn t washed their hands before handling a central line. Anyone can wave a red flag, Carter says. This empowers everyone. comments to notablenursing@ccf.org. We want all healthcare providers to know that vigilance in watching for patients who are at risk for fall events is not just a nurse issue. Raquel Bryan, RN

7 Notable Nursing Spring 2014 ICU Immersion Program Eases New Nurses Toward Optimal Bedside Care Training focuses on critical thinking to improve clinical decision-making. Making the transition from classroom to bedside is challenging for any newly graduated nurse, but for those working in an intensive care unit (ICU), it can be especially daunting. An innovative, grant-funded ICU Immersion Program at Cleveland Clinic seeks to ease the transition. For newly hired RNs, the immersion program provides intensive, specialized training that builds more than just technical skills. The program s methodologies are focused on moving away from didactic content and creating patterns for critical thinking that result in better clinical decision-making and improved patient outcomes, says Christine Szweda, MS, BSN, RN, Senior Director, Operations, Office of Nursing Education. The ICU Immersion Program includes 40 hours of intensive classroom/simulation lab time outside of the unit in addition to the standard 12 weeks with a preceptor before nurses are assigned to the floor independently. The National Council of State Boards of Nursing funded the immersion program as part of a randomized controlled trial; the training is the intervention and there is a nonparticipating control group. The study has consented 65 ICU nurses since it was initiated in the second half of Impetus for ICU training As part of its new-hire orientation program, Cleveland Clinic uses the Performance Based Development System (PBDS) to assess all nurses. With PBDS, nurses view simulated video vignettes. Then, they are presented with a variety of clinical situations and asked to identify the best action to take in each situation. Nurse educators targeted ICU nurses for the intervention because historically ICU nurses had the lowest percentage improvement in PBDS scores on reassessment. Common clinical problems that new nurses often misunderstand include issues such as increased intracranial pressure, an obstructed airway, shock and pulmonary embolus. One possible reason new graduates working in the ICU have not done as well could be the traditional focus on acquiring multiple technical skills versus the focus on critical thinking, as there are multiple types of drains, lines and equipment to be preoccupied with, says Ned Sormaz, RN, CCRN, one of the ICU Immersion Program facilitators who is a Clinical Instructor in Cardiovascular and Vascular ICUs. 5

8 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable Key Questions ICU Immersion Nurses participating in simulated patient scenarios in Cleveland Clinic s ICU Immersion Program are asked three questions after receiving a patient report and prior to seeing the patient: What complication(s) is the patient at risk for? How will you know if that complication is occurring? What particular components of the assessment are you going to focus on? 6 How it works Nurses assigned to the immersion program undergo the 40 hours of additional training in eight-hour increments; either five days in a row or over a period of weeks. The training uses high-fidelity simulation manikins and ICU patient scenarios so new nurses can work through clinical situations similar to those in their units. The immersion program teaches nurses to look at the patient history, anticipate immediate patient risk factors, and discuss how they would recognize if a problem were occurring, Szweda says. The assesssment increases the chances that nurses will pick up on a subtle sign or symptom before patients are at the point of decompensation. (See sidebar for a real-world example.) The repetitive questions used in the training are extremely effective in teaching nurses to work through a complex clinical scenario, Sormaz says. We find that by asking the same critical thinking questions over and over with intent, new nurses establish a pattern for putting the clinical puzzle pieces together. The goal is for skills to translate into clinical practice; we want nurses to ask those same key questions on the unit. All of the critical thinking questions are open-ended questions, says Migdalia Serrano-Smith, MSN, RN, CCRN, one of the ICU Immersion Program instructors and Nursing Skills and Simulation Lab Coordinator. We want new nurses to think through the key questions. We are there to facilitate discussion in order to help nurses develop their critical thinking, she says. The training also includes stop and grow debriefing in which a simulation is paused so that nurses can talk about what they just experienced and instructors can ensure they are on the right track. Working in the ICU is very fast-paced, and the ICU Immersion Program does a great job of slowing things down a bit to increase your comfort level, says Kaitlin Kurowski, RN, surgical ICU nurse. Even with a preceptor, being an ICU nurse for the first time can be somewhat scary. The immersion program helps you be more prepared. The critical thinking skills that nurses learn what s going on with the patient, what to expect, why is this happening, what could be happening guide nurses to think that way when they are on the floor. Promising initial results By all counts, the intervention which was initiated in the second half of 2013 appears to be working, based on both quantitative and qualitative metrics.

9 Notable Nursing Spring 2014 After nurses see the patient, they are asked these questions: What signs/symptoms do you see? What problem/complication do you think is occurring and why? Does this require any urgent action(s) and why? What immediate nursing interventions do you need to take and why? What information do you need to communicate to the physician? What orders are you going to anticipate from the physician? What is the rationale for those orders? How will you know the interventions/ orders implemented have been effective? At the study s midpoint, the number of ICU nurses achieving an acceptable percentage on the PBDS increased by 25 percent from baseline. The study is on track to achieve an end target of a 50 percent improvement, Szweda says. Participants reflected on their feelings at the end of the ICU Immersion Program. They said it: Increased confidence in clinical decision-making Improved ability to anticipate clinical problems better than at the start of the program Improved technical skills Helped them to be better organized when calling a physician for a patient problem What s next The ICU immersion study is just one example of a concerted three-year effort in which the Office of Nursing Education and Professional Development has delved into strategies to help new graduate nurses develop. We plan to take lessons learned from this study and other programs that we have initiated and integrate them into a formalized residency program for ICU nurses, Szweda says. comments to notablenursing@ccf.org. One nurse s experience Changing Patient Outcomes For the Better Kent Heglaw, RN, who works in the surgical ICU, says he carries the training that he received in the ICU Immersion Program with him every day that he goes into the unit. Heglaw, who completed the training last fall, recounts a recent patient encounter in which the immersion training likely resulted in an improved patient outcome. During the encounter, he noted that the patient was having some respiratory issues. Without the training, Heglaw says, he may have simply made a notation in the chart and moved on. Instead, a little itch in my brain told me that I should suggest a CT scan, he says. I made the recommendation to the doctor, and he said, That s a great idea do it now. As a result of the CT scan, a critical respiratory issue was diagnosed, and the patient received what may have been life-saving treatment. Had it not been for the ICU Immersion Program, Heglaw says, I don t think that I would have had the same confidence in my clinical assessment to take that extra step and make the recommendation to the physician. 7

10 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable Innovation in Education Dedicated Educational Unit Program Focuses on Closing Practice Gap During Clinicals 8 The last student I worked with managed intravenous lines, inserted a nasogastric tube successfully, and even saw a tracheotomy, which is not common in our patient population. Marcia Paasewe, RN

11 Notable Nursing Spring 2014 Angela Tolone, BSN, RN, with nursing student Kristin Kidney Frontline staff nurses serve as clinical education partners, shaking up the traditional preceptorship model. It s not unusual for nursing students to compare notes with fellow students, and Kristin Kidney is no different. Kidney is participating in a pilot at Cleveland Clinic called the Dedicated Educational Unit (DEU) program that offers immersive training by frontline staff nurses during clinical experiences rather than a traditional student model that includes one clinical faculty with multiple students. The DEU program has given me such a different experience than most nursing students I ve talked to, and it s made me feel confident, comfortable and prepared, Kidney says. It s pretty much a practicum for the entire clinical experience. You work actual nursing shifts through the whole program, not four hours like you do in a traditional clinical experience. You also receive hands-on, one-on-one training from experienced floor nurses caring for multiple patients, and you re able to do pretty much everything they do under their supervision. Students in the DEU program work with clinical education partners (CEPs) Cleveland Clinic floor nurses who receive specialized education and serve as coaches and teachers. The rotation includes 72 hours of clinical experiences per month, with three months of medical-surgical areas and one month in various specialty areas, including labor and delivery and postpartum, pediatrics, intensive care and behavioral health/psych and then a practicum. They have the same number of clinical hours as traditional students, but in a different format, explains Jennifer Van Dyk, DNP, RN, Director of Nursing Education for Student and Faculty Onboarding, who is leading the pilot program. While this educational approach is not new, it recently has started to gain momentum, Dr. Van Dyk says. What s novel about this program is that we are carrying it out in a multihospital system within a large enterprise. As far as I know, a DEU program hasn t been done before on this scale, she explains. We are operationalizing this approach and customizing it to our needs. Focus on real-world experience Cleveland Clinic is analyzing whether the DEU program has more benefits than traditional clinical learning in which a nursing school instructor works with multiple students, sometimes eight students at a time, each of whom is responsible for one patient at a time and sometimes in more of an observational role than a hands-on role. We are testing this program because we identified a practice gap a functional gap that we routinely observe between the time that we hire new graduates and when they can start functioning independently in a staff nurse role, Dr. Van Dyk says. The DEU program allows nursing 9

12 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable students to have real-life practical experiences right from the beginning. Their clinical time is spent in a more realistic manner that teaches them how critical thinking and different aspects of care planning fit together to bring about positive patient outcomes. She adds: This is an innovative way to address the practice gap. It is important to implement and assess the effectiveness of alternatives to traditional nursing education. Measuring the pilot program s outcomes Students are able to learn what it s really like to be on a unit where one nurse may have six patients with six families and at least six different doctors much different than a traditional model where students typically only take on one patient assignment at a time. Students in the DEU program are exposed to a lot of experiences, says Marcia Paasewe, RN, a CEP for the program and a medical-surgical urology nurse. The last student I worked with managed intravenous lines, inserted a nasogastric tube successfully, and even saw a tracheotomy, which is not common in our patient population. 10 Kristin Kidney (left) on a unit with Nicole Ball, RN (right) The success of the Dedicated Educational Unit (DEU) pilot program will be monitored through a number of metrics, including: Length of orientation for nurses who are hired First-year turnover rates Critical thinking scores, as measured by critical thinking skills tests given in nursing school, and by scores on the Performance Based Development System (PBDS) assessment that Cleveland Clinic administers to all new hires Qualitative interviews with students and clinical education partners One-on-one training So far, three cohorts have participated in the program, and the first 11 students, including Kidney, graduate in May. All students are part of the Breen School of Nursing at Ursuline (Ohio) College s 15-month BSN program for students who already have an undergraduate degree. The program allows students to have more hands-on opportunities and autonomy, as long as we are overseeing them, says Sue Martau, RNC-OB, a CEP for the program who is a labor and delivery nurse. Labor and delivery is a fast-paced unit, and if patients need something, they need it right then and there. Students can do more because they don t have to call the instructor first as they would in a traditional program. Jim Pehotsky, RN, a CEP for the program and charge nurse in behavioral health/psychiatry, says he enjoys mentoring students and seeing their growth. It s fun to watch the lights come on, and very rewarding to see them get it, he says. It s also a good feather in the students caps to have done this. Although the program is resource-intensive, since the CEPs use time and resources to work with DEU students, it s well worth the investment, the CEPs say. The program is a huge benefit for the students and in the end, a huge benefit for nursing, Martau says. When these students are eventually hired after graduation, they are going to be much more comfortable as bedside nurses. Additionally, in prior research about a DEU program, the researcher demonstrated reduced orientation time and first-year employment turnover. comments to notablenursing@ccf.org.

13 Best Practices Notable Nursing Spring 2014 Having a Co-Charge Nurse Ensures Better Patient Safety Joanna Trivisonno, BSN, RN (left), and Melissa Hecker, BSN, RN Caring for high-acuity patients is all in a day s work at Cleveland Clinic s echocardiography laboratory. But one day in January, the lab was flooded with crises. Charge nurse Joanna Trivisonno, BSN, RN, and her team of nurses were already juggling daily responsibilities, preparing patients for procedures in the echo lab and helping conduct cardiology studies at patient bedsides around the hospital. Trivisonno was stationed in the echo lab s recovery room, managing recovering patients, answering the frequently ringing telephone, dealing with changing procedure schedules and more. Suddenly, one patient s blood pressure began to drop. Two others began having complications from sedation. It was more than Trivisonno and her medical assistant could manage. That s when Trivisonno turned to Melissa Hecker, BSN, RN, a co-charge nurse assigned to her that day. Having a co-charge nurse is like having a second brain and an extra set of hands, says Trivisonno. With a co-charge, I can do more to ensure patient safety and improve work flow and efficiency. Two leaders make unit run smoother The echo lab has been operating with charge and co-charge nurses for almost a year. The duo-charge concept was suggested by former echo lab nurse Kirk Scheckel, RN. Nurses in the unit liked the idea and pilot tested it for several months before the charge and co-charge nurse roles became standard practice. Charge nurses were surveyed about the unit s safety and work environment both before and after adding a co-charge nurse. Results of the latter survey showed an approximately 80 percent improvement in charge nurses ability to maintain patient safety and perform quality work. It s safer for our patients many of whom are high-acuity, post-op patients when there are two nurses on hand with seasoned critical-thinking and assessment skills, says Trivisonno. Now, I don t need to worry about a patient needing me while I m handling a phone call or doing something else to manage the unit. In addition, the latter survey showed a 136 percent improvement in fostering a stress-free work environment, which benefits patients as well as staff. How it works Cleveland Clinic s echo lab has nine nurses who serve on rotating schedules. Four rotate as the charge and co-charge nurses. The charge nurse directs the co-charge nurse, who works alongside the charge nurse and fills in when the charge nurse is away from the unit; on lunch break for example. Because only trained charge nurses fill either role, two experienced leaders are always on duty. The co-charge nurse knows what it s like to be a charge nurse, so the person in this role often knows what the charge nurse is thinking and what the next steps should be, says Trivisonno. When I m in charge, having a co-charge nurse is extremely helpful, says Hecker. The co-charge nurse supports me, offering input. I m never alone when I need to make decisions. When I m the co-charge, I feel great satisfaction supporting my charge nurse, working as a team. They agree that the co-charge nurse concept may benefit other hectic nursing environments where patient safety is top priority. It could be valuable to have charge and co-charge nurses covering other units with prep and recovery areas, particularly where patients are recovering from sedation, says Hecker. comments to notablenursing@ccf.org. 11

14 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable Initiating Innovation Systemwide Program Puts Nurses at the Forefront of Trialing New Ideas, Technologies and Processes Diane Cleary, BSN, CMSRN 12 The healthcare landscape is continually evolving and nurses must not only change with it, but be in the vanguard. For us to remain competitive, practice at the top of our capabilities and ensure high-quality care and great clinical outcomes, we need to constantly revisit what we do and challenge ourselves to find better, faster and less expensive ways of achieving excellent nursing care, says Nelita Zytkowski, DNP, MS, NEA-BC, RN-BC, FHIMSS, Associate Chief Nursing Officer for Informatics at Cleveland Clinic. Last fall, Cleveland Clinic s Zielony Nursing Institute launched its Ideas 2 Innovation (I2I) program to identify, prioritize and test innovative approaches to nursing and patient care. Three units were selected within the health system to trial novel ideas, technologies and processes. The I2I program creates a living laboratory for nurses. Nurses are free to complete product evaluations and research trials of nursing practices or devices, and quality or continuous improvement initiatives, then disseminate results to the rest of the Nursing Institute, explains Dr. Zytkowski, who serves as co-chair of the I2I council that is overseeing this program. The I2I units were established on medical/surgical floors at Cleveland Clinic s main campus and two community hospitals Hillcrest and Lakewood. The units selected met the following criteria: Representation of the broadest nursing population Strong nurse manager leadership Adaptable staff open to change Tradition of successful clinical outcomes Willingness to undergo infrastructure changes, minor construction and unit modifications The scope of this initiative goes well beyond testing new products or devices. When some people think about the word innovations, gadgets and systems immediately come to mind, says Dr. Zytkowski. In our I2I program, the whole nursing experience is taken into account. The council, comprising a dozen representatives throughout the Zielony Nursing Institute, will select innovations for trial that fall into many categories, including people, processes, technology and outcomes. The council hopes to implement at least one project each quarter in Sue Collier, DNP, BA, RN, NEA-BC, believes nurses are the ideal caregivers to trial innovations. By virtue of their 24/7 presence in hospitals, nurses are the coordinators of the care team, says Dr. Collier, CNO and Vice President of Hillcrest Hospital and a member of the I2I program council. As nurses increasingly wear the mantle of multidisciplinary team leader, their advocacy skills lead to trying new processes and new equipment to provide safer, more efficient care for patients. First project underway The first approved project began on all three units in January. Nurses are evaluating an automated lift seat for a bedside commode. It s like an easy chair that safely gets the patient from a sitting to standing position using a hydraulic lift, says Dr. Zytkowski. The goal is to decrease patient falls and caregiver-related injuries during a time when both patients and caregivers are at a high risk for harm. This inaugural I2I unit project may lead to

15 Executive Editor Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM associate chief nursing officer, office of Research and innovation Address comments on Notable Nursing to Nancy M. Albert, Summit Lauds Nursing Innovations Last October, Cleveland Clinic held its inaugural Nursing Innovation Summit. The day-long program, sponsored by the Zielony Nursing Institute s Office of Research & Innovation, inspired attendees to bring innovative thinking and creativity to their workplaces and facilitate new ways of advanced nursing. Nurses with marketed innovations and those developing or implementing solutions discussed the behind-the-scenes efforts that moved their ideas forward. The following three projects were among those shared: Environmental Sensor to Measure Physiological Stressors of Air and Ground Medical Transport Andrew Reimer, PhD, RN Medical transport plays a critical role in transferring patients from smaller referring hospitals to large academic medical centers. However, patients who are transferred from one hospital to another experience increased mortality. To better understand how transport affects patient outcomes, Reimer designed, built and demonstrated feasibility of a sensor that measures the environmental stressors of medical transport. This pilot study and development of an all-in-one sensor is the first real attempt at developing a device capable of capturing the data necessary to assess the impact that the physiological stressors have on patients, says Reimer. Then we will be able to design interventions to improve patient comfort, decrease their overall exposure to the transport environment and ultimately impact their morbidity and mortality. Clinical Nurse Specialist Work Jennifer Colwill, MSN, RN, CCNS, PCCN When Colwill became a CNS, she wanted to fully comprehend the broad scope of her job. She began keeping lists of her tasks, then developed a tracking tool. Next, she conducted a research study using the tool to quantify and understand CNS work. Today, Colwill is working with a mobile application developer to create a practical, innovative mobile app that can capture and quantify the work of any advanced practice nurse (APN), then tie their work to outcomes. Nursing implication of understanding APN work and the impact of work on outcomes is that new knowledge can be used to make decisions about efficiencies and priorities. Further, hospital leadership can ensure the right group is used in the right way to provide positive outcomes at the right cost, she says. Fall Events in Patients with Cancer Luann Capone, MSN, MPA, RN Fall event prevention in hospitalized patients is an important nursing quality indicator, yet current fall risk tools are global; they do not consider factors specific to patients hospitalized for cancer management. We conducted research to address the gap in knowledge, says Capone. As a result we were able to create a fall risk tool that identified seven specific predictors of falls in hospitalized patients with cancer. Most of the factors identified were specific to or more common in cancer care rather than in general medical-surgical care; for example, cancer type and presence of metastasis. The Cleveland Clinic Capone-Albert fall risk tool is an innovation that when used routinely in assessment, may increase nurse vigilance and prevent falls. Editorial Board Sue Collier, DNP, BA, RN, NEA-BC CHIEF NURSING OFFICER, HILLCREST HOSPITAL Janet Fuchs, MSN, MBA, NEA-BC SENIOR DIRECTOR, AMBULATORY NURSING Joan Kavanagh, MSN, RN, NEA-BC ASSOCIATE CHIEF NURSING OFFICER, office of EDUCATION AND PROFESSIONAL Development Mavis Kramer, MBA, BSN, RN, CCRN NURSE MANAGER, LAKEWOOD HOSPITAL Meredith Lahl, MSN, PCNS-BC, CPON SENIOR DIRECTOR, ADVANCED PRACTICE NURSING Sandra Maag, BSN, RN NURSE MANAGER, NURSING QUALITY Mary Beth Modic, DNP, RN, CDE NURSING EDUCATION, MAIN CAMPUS Ingrid Muir, MBA, BSN, RN NURSING DIRECTOR, MEDICINE INSTITUTE AND ENDOCRINOLOGY & METABOLISM INSTITUTE Mary A. Noonen, BSN, RN-BC NURSING EDUCATION, SOUTH POINTE HOSPITAL Christine Szweda, MS, BSN, RN SENIOR DIRECTOR OPERATIONS, NURSING EDUCATION Jennifer Van Dyk, DNP, RN Director, nursing education Linnea VanBlarcum, MSN, RN, ACNS-BC PATIENT CARE SERVICES, LUTHERAN HOSPITAL Dana Wade, MSN, RN, CNS-BC, CPHQ, NEA-BC associate chief nursing officer, office of quality and practice Susan Wilson, BSN, RN, CCRN NURSE MANAGER, MAIN CAMPUS Marianela (Nelita) Zytkowski, DNP, MS, NEA-BC, RN-BC, FHIMSS ASSOCIATE CHIEF NURSING OFFICER, office of INFORMATICS Adrienne Russ Managing Editor Amy Buskey-Wood Art Director Photography tom merce, russell lee, john stillman Mandy Barney Marketing Manager Visit clevelandclinic.org/notable and click on the Notable Nursing tab to add yourself or someone else to the mailing list, change your address or subscribe to the electronic form of this newsletter.

16 Initiating Innovation continued development of a screening tool to help nurses identify patients who can benefit most from an automated lift seat design for toileting. 14 Prior to evaluating the lift seat, each unit collected baseline data on patient fall event rates related to being on a commode and nurse injuries sustained when helping patients. Nurses will collect similar data during a product evaluation approach, then compare outcomes. Although the project is in its infancy, the lift seat reactions at Hillcrest Hospital have been generally positive, from both nurses and patients. In addition, unit staff are excited to participate in more projects. Participating in this initiative means we will be given an opportunity to truly affect the future of nursing and not only the products we use, says Matthew Drew, MS, BSN, RN, Nurse Manager of the I2I unit at Hillcrest Hospital. It will allow us to look at making processes safer for patients and allow for better workflows for the staff. Lakewood Hospital CNO Mary Sauer, MBA, BSN, RN, NEA- BC, is honored that one of her units was selected for this initiative. It s very important that we look at our practice and ways we can do things better for patients, says Sauer, who is a member of the I2I council. For us to continue to thrive, we need to continually ask how we can do things differently. Following the launch of its first project, the I2I council began considering several other project proposals, Kathleen Rorapaugh, BSN, RN including a pilot of a wireless monitoring system for hand hygiene. A systematic approach to innovations The Zielony Nursing Institute developed a project workflow framework to ensure all ideas are carefully considered and that the best ones are assessed or implemented. It begins when a caregiver submits an idea for a project to the I2I council. The contact person can be a nurse, administrator, outside vendor or anyone with an innovative idea. Next, the council reviews project requests. Feasibility, target audience, risks, benefits, cost to implement and use, and other project features are assessed. If the project is selected, a member of the council is assigned to sponsor it. The sponsor partners with the project contact and the I2I governance team to coordinate efforts. After approved projects are executed, the project contact reports back to the council with outcomes and recommendations about whether to move forward with the project enterprisewide. Alternately, council members may recommend further assessment in other work settings or may wish to adapt the process or system and reassess it in the same setting. The I2I unit initiative has great potential to enhance quality of care through alignment of people, processes, outcomes and technology. Equally important, it lets bedside nurses be change agents, innovators and leaders of transformation. It is very important for our nurses to realize that they have great ideas on how to efficiently care for patients and that their ideas can be put into practice, says Diane Cleary, BSN, CMSRN, Nurse Manager of the I2I unit at main campus. Even the smallest idea can make a difference and change a patient s experience. comments to notablenursing@ccf.org. Matthew Drew, MS, BSN, RN

17 Notable Nursing Spring 2014 Best Practices Oncology Infusion Team s New Program Engages Nurses, Improves Patient Compliance and Satisfaction For cancer patients, marking milestones is an important part of treatment. The nursing team in the Infusion Center at Medina Hospital, a Cleveland Clinic community hospital, implemented the new Lions, Tigers & Bears Program to support patients. As each person completes his or her round of chemotherapy, the team marks the event with a graduation ceremony. This new program has become a part of a patient s care plan for the Medina Infusion Center it s as important as knowing a patient s diagnosis and drug regimen, says oncology nurse Sharalyn Beelen, RN. On patients final days of chemotherapy, we celebrate their progress with a graduation and special gifts, she says. We want to encourage people with cancer to plan ahead and look forward to tomorrow. Each patient receives a card signed by everyone on the team, including the patient s physician, along with a large individualized stuffed teddy bear and balloons. They also receive a two-year planner that highlights the one-year anniversary (to come) of their last round of chemotherapy. The money for these gifts comes from the Cancer Services Fund, which is part of the hospital s Foundation. The practice began in December 2012, and thus far some 60 patients have been celebrated and the team has received dozens of thank-you notes, letters and holiday greetings in return. On Theresa Keeler s last day of chemotherapy, she said this about the program: When I was first diagnosed with Stage 4 breast cancer metastasized to the bone, I was absolutely devastated. I figured it was a death sentence. When I got the bear and realized the worst was over, my relief was palpable. It was and still is a reminder that God and my healthcare family can help me get through anything. By survey data, there has been a marked increase in patient satisfaction. In the 2013 Press Ganey report, the Medina Infusion Center was in the 94 th percentile in patient satisfaction, with all answers about infusion therapy in the 90s. This program has done wonders for our patients, says Mir Ali, MD, of Cleveland Clinic Regional Oncology. When patients with cancer have a real sense of belonging and being cared for, they are more compliant with their treatment and more willing to share their concerns. This makes a big impact on patient outcomes. Beelen says the Lions, Tigers & Bears program promotes a sense of team cohesiveness. It helped a new group of nurses and healthcare professionals who never worked together before to have a common purpose, she says. Our physicians are right there reminding me when the last chemo is due and offering congratulations and encouragement to patients. The team also provides patients with a courage kit at the beginning of chemotherapy. It is filled with helpful items, including a book, sunscreen, socks, gloves, candies, a blanket, and a multicolored wrist band that reads No one fights alone. We all wear these wrist bands to remind our patients that they are not alone in their fight, says Beelen. This is what putting patients first is all about. In addition to Beelen, the team implementing the Lions, Tigers & Bears Program at Medina includes Patricia Plack, RN; Kathy Over, RN; Greg Bates, MA; Kathy Pacanovsky, PSR; and Mike Damore, RPHT. comments to notablenursing@ccf.org. 15

18 The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable Research: Factors Associated with Chest Tube Management Time Nurses in one of Cleveland Clinic s cardiovascular intensive care units gained insight into the time it took to manage chest tubes, and learned patient factors associated with management time during the first 24 hours of cardiac surgical postoperative care. 16 The research study found that early after cardiac surgery, nurses spent more time managing chest tubes in patients with a history of previous coronary artery bypass graft (CABG), valve surgery and heart failure, and when taking preoperative anticoagulant medications. When patients had three or more chest tubes, nurses spent more time managing them. Also, smaller chest tube size and nurse caregivers with less comfort in chest tube care were associated with more time spent managing chest tubes. Of all factors studied, chest tube management time was highest for patients who were reoperated for bleeding or tamponade. Myra Cook, MSN, RN, ACNS-BC, CCRN, CSC, principal investigator of the study (pictured above), used an investigator-developed case report form to learn the amount of minutes spent taking care of chest tubes, reinforcing dressings and dealing with patient-reported pain related to chest tube management. In total, 364 patients and 29 nurses were enrolled. Bedside nurses provided information about themselves and their comfort with managing chest tube care. Most non-chest-tube-related patient data was pulled from a hospital database. More than three-fourths of nurses were very comfortable with general management of chest tubes; however, only 41 percent were comfortable managing clogged chest tubes. Laura Schenck, MBA, BSN, RN, CCRN, a study coinvestigator, said the results were not surprising. Research results confirmed and validated nursing care experiences at the bedside, she says, and provide us with implications for nursing practice in the future, especially related to orienting newly hired nurses. Now that we have quantified how much time it takes to manage chest tubes, Cook says, results will help us know the patients [or their conditions] that may require more nursing time. We can plan nursing care knowing the time needed to perform care requirements, and we can anticipate patient needs. We hope to employ strategies that improve nurses time spent on this type of care. Schenck says a physician-led research study that involved clot removal using a new type of chest tube sparked the team s interest, especially because research papers were limited and off-topic. Chest tube management can take more time than assumed. Study results provide new knowledge about time needed to complete nursing actions, patients pain responses, and nurse and patient characteristics associated with chest tube management. comments to notablenursing@ccf.org.

19 Notable Nursing Spring 2014 NEA-BC CCNS PCNS-BC CPON CCRN PNP-BC ACNS-BC CDE CCRN RN-BC CCNS CSC CHFN CDE CCNS PCNS-BC CPON CCRN PNP-BC ACNS-BC Research: Improving Nurse Certification Rates Clinical specialty certification can have a positive impact on registered nurses job satisfaction, and in other research, was associated with feelings of empowerment and collaboration with colleagues. Certification was also associated with better clinical outcomes. A group of Cleveland Clinic nurses set out to examine nurses value of certification, and determine if nurse characteristics and barriers to certification were associated with how nurses valued certification and if they were likely to certify in the future. In May 2013, Deborah Solomon, MSN, RN, ACNS-BC; Meredith Lahl, MSN, PCNS-BC, PNP-BC, CPON; and Marian Soat, MSN, RN, CCNS, CCRN, launched a prospective correlational study using survey methods. Under the mentorship of Mark McClelland, DNP, RN, CPHQ, the team surveyed nurses across the Cleveland Clinic health system using the Perceived Value of Certification Tool, and investigator-developed questionnaires of demographics, barriers to certification and likelihood to certify in the future. Of 1,589 participating nurses, there were four characteristics associated with nurses value of certification: being a member of a professional organization, caregiver role in the workplace, certification status and number of years working as an RN. The five barriers to pursuing certification were: Not having preparatory material No desire or interest in getting certified Feeling it was not relevant to practice Not having institutional support Certification expense Nurses response regarding not having preparatory materials was interesting, Lahl says. We have materials available and need to ensure nurses are aware of resources. Study findings, Solomon says, spurred a movement to heighten awareness of the many resources available to nurses to enhance their professional development. We see many more hands go up when asked during a review course, Who is going to go for certification? she says. Nurses likelihood to certify in the next six months increased when study participants knew a certified nurse on their unit, if they had taken a review course, and if they were a member of a professional organization. Although most survey respondents did not think that certification increased salary, Lahl and Solomon agreed that it shows a commitment to professional development, which enhances marketability. Almost half of Cleveland Clinic nurses are certified. Certification, as defined by the American Board of Nursing Specialties, is the formal recognition of the specialized knowledge, skills and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes. Solomon says that research results will be used to make recommendations to nursing leadership aimed at increasing nurses value of certification. Key themes might be to promote membership in professional organizations, provide more diverse and accessible preparatory education, and recognize nurses who achieve certification. comments to notablenursing@ccf.org. 17

20 The Cleveland Clinic Foundation 9500 Euclid Avenue / AC311 Cleveland, OH Cleveland Clinic (main campus) Fairview Hospital euclid Hospital lakewood Hospital MARYMOUNT Hospital SOUTH POINTE HOSPITAL Awards Cleveland Clinic Florida nurse practitioner Debra Hain, PhD, APRN, ANP-BC, GNP-BC, was inducted as a 2014 fellow of the American Association of Nurse Practitioners. AANP impacts national and global health by engaging recognized nurse practitioner leaders who make outstanding contributions to clinical practice, research, education and/or policy. Several nurses of the Zielony Institute were presented with the 2014 Annual Infection Specialty Award by the Society of Critical Care Medicine at the January meeting. They were recognized for Stay Connected to Cleveland Clinic 13-NUR-1594 outstanding research contributions for their team abstract A RCT of Infection Rates in ICU Environments by EKG Lead Wire Type: Disposable and Cleaned, Reusable. Recipients included Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC; Ellen Slifcak, BA, RN; Katrina M. Hartig, MS, BSN, RN, NE-BC; Gregory Horvath, MBA, BA, RN; Heather Lachiewicz, MSN, RN, CCRN, CNML; Victoria Rhoades, BSN, RN, CCRN; Terri Murray, MSN, RN; Joel D. Roach, BA; Rosslyn Van Den Bossche, MBA, BSN, RN; Nemy Vargas, MSN, RN, CCRN, CEN; and Sue Wilson, BSN, RN, CCRN. For same-day appointments, call CARE (2273). For 24/7 REFERRALS, call 855.REFER.123 ( ). The Cleveland Clinic Way By Toby Cosgrove, MD, CEO and President of Cleveland Clinic Great things happen when a medical center puts patients first. Visit clevelandclinic. org/clevelandclinicway for details or to order a copy. Scan this code for details on the Zielony Nursing Institute s wealth of upcoming conferences.