Clinical Nurse Specialist Practice Across the Continuum

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1 Clinical Nurse Specialist Practice Across the Continuum Angela Rowe, MSN, APRN, PCNS-BC Pediatric Clinical Nurse Specialist Arkansas Children s Hospital Presentation ID: CD3

2 Disclosure Today s presenters do not have any relevant financial interests presenting a conflict of interest to disclose. Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation. The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non-ache) for this program toward advancement, or recertification in the American College of Healthcare Executives.

3 Objectives Participants will define the components of the Clinical Nurse Specialist (CNS) Continuum of Care Model. Participants will recognize the impact of a Clinical Nurse Specialist Continuum of Care Model on outcomes in patient populations with complex conditions. Participants will describe processes that can be improved to ensure appropriate follow-up and transition to home and community for complex care patients.

4 Arkansas Children s Hospital Overview Only pediatric hospital in Arkansas Non-profit, independent hospital Centrally located in Little Rock 316 beds 20+ outpatient clinic locations Over 80 subspecialties Contains only burn center in the state Partnership with UAMS

5 Arkansas Children s Hospital

6 Clinical Nurse Specialist (CNS) Role Licensed registered nurses who have graduate preparation (Master s or Doctorate) in nursing as a Clinical Nurse Specialist. Clinical Nurse Specialists are expert clinicians in a specialized area of nursing practice. 3 Spheres of Influence Patient Nurse System Influence care outcomes by providing expert consultation for nursing staffs and by implementing improvements in health care delivery systems.

7 CNS Continuum of Care Model Data driven, incorporates a systems view, and requires involvement of all stakeholders System level problem solving to standardize care and promote quality care Focus on communication among the interdisciplinary team, patient and family education, and nursing sensitive outcomes Facilitates flow of information and problem solving to ensure care provided is fluid, comprehensive, and evidence-based to optimize outcomes

8 CNS Continuum of Care Model CNS Inpatient admissions Nursing Practice Systems problem-solving Outpatient Complex/chronic Planned admission (i.e. surgical, medical) Patients already connected in ACH Specialty Clinics Quality Patient Outcomes with Established Measures Discharge Community: PCP, School nurses ACH F/U: Specialty Clinics, General Further referral (i.e. Duke, Mayo, etc.)

9 Model Application The CNS Continuum of Care Model has been applied to the following patient care/system processes: Improving patient satisfaction scores on two medicalsurgical units Improving skills of school nurses providing care for children with special needs in the school setting Reducing discharge delays in a busy pediatric cardiovascular unit. Decreasing the incidence of surgical site infections through development of a surgical site infection prevention bundle

10 Improving Patient Satisfaction: Background 3E and 4E Medical Surgical Units 3E 17 beds 4E 15 beds Patient population includes: Orthopedics ENT General Surgery Urology Trauma Hematology/Oncology Overflow General Pediatrics Average length of stay: hours

11 Improving Patient Satisfaction: Background Early 2013 Patient Satisfaction below benchmark on both 3E and 4E Surgical Units 3E Overall Quality of Care 4E Overall Quality of Care

12 Improving Patient Satisfaction: Description Staff Perceptions Assessed Patients and Families via Leadership Rounds Information Sharing Team approach to reach the goal

13 Improving Patient Satisfaction: Description Intervention Identification One targeted intervention for each Key Driver General Interventions Key Driver Doctor Involving Patient in Decision Making Process Discharge Process Staff Courtesy and Friendliness Teamwork between Doctors, Nurses and Staff Nurses Respect for Patient Privacy Cleanliness of the Hospital Intervention Purposeful communication with patients and families Discharge rounds and folders Public recognition of staff with patient comments RN led rounds Scripting with patient and family involvement De-clutter patient rooms

14 Improving Patient Satisfaction: Description Team Approach Engaging our multidisciplinary partners Transparency Bridging the Continuum

15 Improving Patient Satisfaction: Outcomes Staff engagement Increased patient satisfaction 3E Overall Quality of Care 4E Overall Quality of Care

16 Improving Patient Satisfaction: Implications for Practice Engagement and buy-in of frontline staff Leadership presence, engagement, and support Mentor, coach, and grow

17 Improving Patient Satisfaction: Implications for Practice Monitor, monitor, monitor Celebrate your successes Each encounter MATTERS

18 Improving Skills of School Nurses: Background Demand for school nursing services Increasing number of students with chronic health conditions Complexity of medical conditions

19 Improving Skills of School Nurses: Background Arkansas School Nurse Survey, Survey: 258 school districts (public & charter) 436,471 students Response: 149 school districts 413 School Nurses 229,742 students 4,740 students requiring specialized care

20 Improving Skills of School Nurses: Background Children Requiring Specialized Care at School:

21 Improving Skills of School Nurses: Background Why get involved? Many of these school children are followed by Arkansas Children s Hospital Strengthen community relations and care of our patients by assisting school nurses

22 Improving Skills of School Nurses: Background School Nurses were asking for much more than just information Improving clinical support for school nurses Pediatric nursing skills Connection to expert resources

23 Improving Skills of School Nurses: Description CNS Continuum of Care Model: Expand CNS role to serve as Liaison to School Nurses

24 Improving Skills of School Nurses: Description CNS Liaison to School Nurses Central point of contact for information School Nurse s Requests Patient questions Skills questions HIPAA

25 Improving Skills of School Nurses: Outcomes CNS as Liaison to School Nurses Collaborate with State School Nurse Consultant to get the word out Coordinate resources Develop Pediatric Skills Education for School Nurses

26 Improving Skills of School Nurses: Outcomes 5 most commonly requested skills Tracheostomy Management Gastric Tube Feeding Seizure emergencies Urinary catheterization Central venous access devices Simulation technology-assisted skills training for school nurses

27 Improving Skills of School Nurses: Outcomes Pediatric Skills Education Day On-site at the Regional Educational Cooperatives 120 School Nurse participants to-date 4 of 5 major Regions Leaders APRNs and RNs Simulation Specialists Community Health Nurse Specialists State School Nurse Consultant

28 Improving Skills of School Nurses: Implications for Practice Resources and connections improved for School Nurses Organizational system Future work

29 Reducing discharge delays: Problem: Delays in patient flow Background Cancelled surgeries / back logged schedule Delays intraoperatively with reduced OR room turnover Anesthesia/OR staff cost Decreased patient satisfaction scores on discharge preparation

30 Reducing discharge delays: Background Cause: Lack of standardization regarding anticipation and planning for discharge Inconsistencies in rounding and planning for discharge Discharge criteria inconsistently established, a moving target

31 Reducing discharge delays: Background Goal: re-design the discharge process to achieve more timely and efficient discharges 1) improve bed turnover 2) decrease patient delays in the CVOR and ICU 3) improve parent satisfaction 4) lessen the risk of errors that occur with rushed discharges and fast-paced patient turnover.

32 Reducing discharge delays: Description Data collection re: discharge process Planning, establishing discharge criteria Timing of discharge teaching Coordination of discharge needs Identification of delays

33 Reducing discharge delays: Description Multidisciplinary group formed with key stakeholders Project champion and leader identified SMART aim identified Specific Measurable Attainable Relevant Timeframe

34 Reducing discharge delays: Description

35 Reducing discharge delays: Outcomes Decrease in # and % of delays June 2012 to Aug 2013 Cause of delays shifted from primarily planning/coordination to parent/familyassociated delays

36 Reducing discharge delays: Implications for practice Financial impact Standardization of process Involve the frontline Engage stakeholders, include data (esp $$) Measure, tweek, measure, tweek

37 Reducing SSI : Background Originally a 15 bed ICU with a 10 bed step-down unit Birth adult patients with congenital heart disease Surgical palliation / repair, implantation of Ventricular Assist device, ECMO, Heart Transplantation program

38 Reducing SSI : Background South Wing expansion/move /renovation completed in Dec 2012, resulting in growth from a 25 to a 40 bed unit Dramatic increase in SSI/mediastinitis rate in 2012

39 Reducing SSI : Background /100 surgical incisions (n=9) /100 surgical incisions (n=2) 4/100 surgical incisions (n=2) Overall rate 1.35/100 surgical incisions

40 Reducing SSI : Background 2012 rate = 3.7/100 primary closures (n=11) 12.3/100 delayed closures (n= 7) SSI = $20,000 with estimated prolonged LOS by 12.2 days (2008)

41 Reducing SSI: Description Establish standard of care via development of prevention bundle to: improve standardization of care decrease variability in patient education improve follow-up Engage all stakeholders data sharing/transparency decision making Increase patient satisfaction

42 Reducing SSI: Description Continuum of Care Improvement Structure SMART aim, key drivers, action plans

43 Reducing SSI: Description SSI Prevention Bundle Detailed preoperative, perioperative, postoperative care measures Establishes standards, reduce variability in care Identifies responsible party, effective date, process measure, process measure goal, compliance reporting

44 Reducing SSI: Outcomes Process measure audits: Preoperative skin prep Antibiotic prophylaxis Postop antibiotic interval Incision dressing status (open or closed) Protection of incision from cross-contamination Compliance with standard for in-unit procedure (OR attire, minimizing entry, etc)

45 Reducing SSI: Outcomes 2013 SSI rate = 1.04/100 (n = 3) 2013 Mediastinitis rate = 4.5/100 (n = 2)

46 Reducing SSI: Implications for Practice Establishing / standardizing best practice Stakeholder engagement! Show the data! Change over time Measure, tweek, measure, tweek Reinforcement Recognizing impact

47 Summary Utilization of the CNS Continuum of Care Model Provides positive outcomes Can be applied to additional organizations and patient populations Provides a framework for bridging the continuum with complex patients

48 Questions Contact Information Angela Rowe, MSN, APRN, PCNS-BC

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