Conflict of Interest Disclosure Statement. Obstacles. Objectives. Doctor of Nursing Practice. The Perfect Storm

Transcription

1 How to Effectively Institute a Scholarly Inquiry/Research Program in a Practice Doctorate Curriculum Conflict of Interest Disclosure Statement I have no financial relationships with any commercial interest related to the content of this activity. John P. Maye, PhD, CRNA, CAPT (Ret) USN Professor/Pain Management Education Coordinator University of South Florida College of Nursing Objectives Discuss how to effectively incorporate scholarly inquiry and development of a research program within a practice doctorate curriculum. Design a strategy to integrate research and clinical evidence throughout the curriculum while still addressing the eight essentials for DNP education. Present for about 30 minutes and then engage in a faculty discussion. Obstacles Dr. Maye, you are such a good teacher, I wish you could teach some of our real classes Thank you, but I prefer to devote my life to teaching people useless information they will never actually use. Undergraduate nursing research curriculum The Perfect Storm AACN position statement on the practice doctorate in nursing recommended that advanced nursing practice education be moved to the doctoral level (AACN 2004) The Patient Protection and Affordable Care Act of 2010 The Electronic Health Record The Electronic Anesthesia Record Doctor of Nursing Practice American Association of Colleges of Nursing The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations Report from the Task Force on the Implementation of the DNP August

2 AACN August 2015 Practice-focused graduates are prepared to generate new knowledge through innovation of practice change, the translation of evidence, and the implementation of quality improvement processes in specific practice settings, systems, or with specific populations to improve health or health outcomes Questions How do you feel about the quality of the DNP projects you are producing? Where do you get your ideas for DNP projects? How do you select topics for DNP projects? When do you select topics for DNP projects? Are all members of the nurse anesthesia faculty involved in the research program or do you have a specific research faculty? Are your research and evidence based classes being taught by nurse anesthesia faculty? Research in the Curriculum The eight essential requirements for DNP education can be addressed through various strategies Limited time for the completion of high quality DNP projects that are worthy of publication and dissemination. DNP projects should be relevant and reflect the most cutting edge topics in the profession. Challenges Faculty are often stretched thin with multiple commitments and the DNP project is not often valued or appreciated for what it can add to the scholarly development of the student and more importantly the faculty How do you develop and manage meaningful DNP projects for 20, 30, 40, or even 50 students annually? Leadership Can we bring value to our profession/programs through the performance of meaningful well conducted research that has value to the institutions we collaborate with? The win/win philosophy by Stephen Covey Hospital Consumer Assessment of Health Care Provider and Systems The incentive for IPPS hospitals to improve patient experience of care was further strengthened by the Patient Protection and Affordable Care Act of Specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program, beginning with October 2012 discharges. 2

3 Meaningful Research Utilization of the electronic health record Utilization of the electronic anesthesia record Quality of care and outcomes from anesthesia and critical care medicine. Collaborate with other disciplines to develop improved evidence based guidelines Develop the next generation of CRNA s to be scholars and advance the profession Sometimes you are good Sometimes you are ugly 8 Essentials for DNP Education 1. Scientific underpinnings for practice 2. Organizational & systems leadership for QI and systems thinking 3. Clinical scholarship and analytical methods for EBP 4. Information systems/technology and patient care technology for the improvement and transformation of healthcare 5. Health care policy for advocacy in health care 6. Inter-professional collaboration for improving patient and population health outcomes 7. Clinical prevention and population health for improving the nations health 8. Advanced nursing practice/specialty curriculum DNP ESSENTIALS Scientific Underpinnings for Practice Organizational & Systems Leadership for QI and Systems Thinking Clinical Scholarship and Analytical Methods for EBP Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Healthcare Health care policy for advocacy in health care Interprofessional Collaboration for improving patient and population health outcomes Clin Prevention and Population Health for Improving the Nations Health COURSEWORK Advanced Anatomy Advanced Health Assessment Advanced Physiology Applied Pathophysiology Advanced Pharmacology Organizational and Systems Leadership in Healthcare Health Economics and Advanced Practice Healthcare Research/Evidence Based Practice Statistics Utilization of Evidence Into Practice DNP Project Healthcare Informatics Ethics and Policy Advanced Practice Role Population Health A proposed strategy Design a strategy to integrate research and clinical evidence throughout the curriculum while still addressing the eight essentials for DNP education Start with one or several clinical situations that will be presented early on in the curriculum and become a theme in all courses Example today is perioperative considerations for the patient at risk for altered renal perfusion This problem may have widespread implications for institutions.. Think big!! Advanced Nursing Practice Specialty anesthesia courses 3

4 A Proposed Strategy Present the actual clinical situation and use it as an example of how to integrate knowledge across the eight essentials for DNP education. Use the clinical situation to reach across specialties and provide students with an appreciation for how their decisions may impact others. Use the clinical situation to guide students toward higher level critical thinking. Use the clinical situation to increase the breadth of knowledge of faculty members and generate DNP project ideas. Clinical Situation Example 76 year old male presents for exploratory laparotomy with history of hypertension and obesity Preoperative medications consist of a beta blocker and an ACE inhibitor Instructed to take his ACE inhibitor with a sip of water on the morning of surgery by his primary care provider Relatively normal case with minimal blood loss (several episodes of hypotension, immediately addressed) appropriate fluid resuscitation and adequate urine output Develops AKI in the postoperative setting and prolonged hospital admission Clinical Questions Ask these questions in any one of the DNP curriculum courses: What is intraoperative hypotension? When intraoperative hypotension occurs at what point should the provider become concerned with postoperative outcomes? Is intraoperative hypotension associated with Acute Kidney Injury (AKI)? Is ACE inhibitor therapy associated with the development of AKI? Should ACE Inhibitors be continued until the day of surgery in all patients? Anesthesiology 2013: Non-cardiac surgical patients in a database of more than 33,000 patients at the Cleveland Clinic. Two main outcomes AKI and Myocardial injury Acute Kidney Injury developed in 2478 patients The MAP threshold where the risk was increased was less than 55mmHg MAP less than 55mmHg for 1-5 min, 6-10 min, and min and more than 20 min had graded increases in their outcomes Clin J Am Soc Nephrol 2007: Retrospective analysis of 504 patients who underwent gastric bypass procedures between 2003 and 2005 at University of Cincinnati Medical Center. AKI was defined as a greater than 50% increase from baseline serum creatinine during the first three postoperative days A total of 42 patients (8.5%) developed postoperative AKI. Hyperlipidemia, preoperative use of ACE-Inhibitors, ARB s, intraoperative hypotension and higher BMI s were all associated with increased frequency of AKI. Hospital for Special Surgery Journal (2011): 65 year old female bilateral knee prosthesis under spinal anesthesia. (HTN, Obesity, hypercholesterolemia, CAD) on Lisinopril, Beta Blocker MAP greater than 60mmHg throughout the case. 1200ml of lactated ringers with 100ml blood loss. Intraoperative urine output 250ml over the 2 hour case POD1 Serum creatinine doubles 0.9mg/dl to 1.9 mg/dl (AKI as defined by the RIFLE Criteria) 4

5 Risk factors for AKI Age (greater than 75 years) CKD (GFR less than 60ml/min/1.73m 2) Cardiac failure Peripheral vascular disease Liver disease/cirrhosis-impairment of liver blood flow Diabetes mellitus Sepsis Hypovolemia Nephrotoxic medications DNP ESSENTIALS COURSEWORK Scientific Underpinnings for Practice Physiology/Pathophysiology Renal Disease Impact of alterations in renal perfusion in the perioperative setting The impact of pharmacologic management for co-morbid medical disorders beyond the traditional setting ACE Inhibitors: provide end organ protection independent of their blood pressure lowering properties in diseases such as congestive heart failure, post myocardial infarction, diabetes mellitus, and renal Drenger et al Circulation: Withdrawal of an ACEI preoperatively is associated with an increase number of cardiovascular events mainly CHF and Postoperative MI. Observational nature of the study does not allow for definitive recommendations regarding perioperative ACEI use. Randomized clinical trials are recommended. Organizational & Systems Leadership for QI and Systems Thinking Clinical Scholarship and Analytical Methods for EBP Systems Leadership in Healthcare making better decisions with regard to patient preparation for surgery Economic impacts of poor outcomes in vulnerable populations Integration of knowledge from physiology/pathophysiology and pharmacology into systems leadership Healthcare Research & Evidence Based Practice Statistical Measures and Analytic Methods: Application and Critique Translating Evidence Into Practice Developing an appreciation of clinical decision making and the impact on healthcare 5

6 DNP ESSENTIALS Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Healthcare Health care policy for advocacy in health care Interprofessional Collaboration for improving patient and population health outcomes Clinical Prevention and Population Health for Improving the Nations Health Advanced Nursing Practice COURSEWORK Developing an appreciation for the electronic medical record, healthcare informatics and information systems for research and clinical decision making Ethics and policy in health systems Develops an appreciation for the advanced practice role and how clinical decisions impact across the health care continuum. Population health and epidemiology in advanced Practice Decision to continue or discontinue an ACE inhibitor may or may not lead to the development of AKI. If AKI develops morbidity and mortality increases substantially in certain populations which impacts health care spending and the nations health. Expands the role of the advanced practice nurse and increases visibility through the development of policy which affects practice. Developing an Evidence-Based Mind Utilizing an actual clinical situation to integrate knowledge from core and specialty course work will guide students and faculty to a higher level of critical thinking. This higher level of critical thinking will generate DNP projects which focus on the translation of new science, its application and evaluation. CRNA DNP graduates will generate evidence through their practice to guide improvements in practice and outcomes of care. Evidence Based Ideas Clinical guidelines regarding the management of complications after peripheral nerve blockade Initiation of anticoagulation therapy after completion of a surgical procedure Multimodal approaches for perioperative pain management for various surgical procedures short term vs. long term outcomes/ healing Preventive analgesic approaches for the management of perioperative pain AACN August 2015 Programs are encouraged to support innovation in the design and dissemination of the final project to reflect the changing healthcare environment. The elements of the DNP Project should be the same for all students and include planning, implementation, and evaluation components. As an outcome of the program, students must have the opportunity to integrate all DNP Essentials into practice. AACN August 2015 The final scholarly project should be called DNP Project to avoid confusion with the term capstone, which is used at varying levels of education. The DNP Project is not a research dissertation; therefore, this term should not be used. AACN August 2015 Group projects are acceptable when appropriate to the students area of practice Goals and project aims should be consistent with the focus of the program Individual contributions should be evaluated with a rubric Each student must demonstrate a leadership role in at least one component of the project 6

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