Group Classes Help Inpatients Take Heart from Each Other
Patients with heart failure need to be “on their game” all the time to stay out of the hospital. That’s how Theresa Cary, MSN, RN, ACNS-BC, CHFN, CCRN, describes the challenge facing patients she cares for as the clinical nurse specialist for the medical cardiology unit on Cleveland Clinic’s main campus. That’s the thinking behind the multidisciplinary Heart Failure Survival Skills Class that Cary manages and helped develop. In the 12 months following the launch of the in-hospital class in January 2012, Cary and her team offered the class more than 140 times to educate 1,200 hospitalized patients with heart failure and their family caregivers. Class participants received information and practical tips to stay healthy and avoid readmission.
A three-pronged multidisciplanary approach
The one-hour class is broken into three 20-minute segments — on medication management, dietary guidance and survival skills — taught by a pharmacist, a dietitian and a clinical nurse specialist. The pharmacist covers why heart failure medications are important, which meds improve survival, which meds make patients feel better and why it’s vital that patients take their meds as instructed. The dietitian then explains why a low-sodium diet is important and — critically — provides practical advice on how to maintain the right diet, including websites and resources on how to eat well, even at restaurants. The clinical nurse specialist leads the survival skills segment, which links recommendations for heart failure self-management to the preceding medication and dietary instructions.
“The survival skills portion weaves together the medication and dietary portions and helps patients apply them practically so they better understand the reasons for postdischarge management recommendations,” says Cary, who usually teaches this portion. “For example, to explain why our Heart Failure Zones handout tells patients to weigh themselves every day and compare that weight to their dry weight, I refer back to the pharmacist’s definition of heart failure and re-emphasize the impact of dietary sodium and heart failure medications on weight.”
The class is offered three times a week in a conference room on Cary’s unit. Class size varies, but six to 10 participants seems to be ideal, she says.
An adjunct to one-on-one teaching
Cary emphasizes that the group classes are meant to complement, not replace, one-on-one education that nurses continue to offer patients. “My portion of the class mirrors some of what nurses are teaching individual patients at the bedside,” she says. What’s different is that the multidisciplinary format allows Cary to better integrate instructions with the reasons behind medication and dietary recommendations, and to translate self-care expectations into practical advice. “It’s an opportunity to bring all the pieces together to help patients make sense of the overall picture and come away with tips on how to survive.”
Strength in numbers
Patients tell Cary the group format adds a vital element as well. “Heart failure is a very difficult condition to deal with, so it’s encouraging for patients to be around others with heart failure and know they’re not alone,” she says. “There are usually a few class participants who are upbeat. Their advice and encouragement is contagious for others who have struggled to manage their heart failure.”
She adds that fellow patients and family members can offer support in ways she never could because she’s not walking in their shoes. “When a fellow patient says, ‘There are so many tasty and healthy recipes out there — let me share some with you,’ it’s a completely different message than if it comes from me,” Cary explains. She and her pharmacist and dietitian colleagues invite that kind of interaction by actively encouraging questions and dialogue throughout the class.
A singular offering
Although group classes for patients are common in outpatient settings, they are far less common in the inpatient setting, and the multidisciplinary aspect of Cary’s group class further distinguishes it.
The class’ multidisciplinary nature was a key to its genesis, as the idea for it had been simmering between Cary and a dietitian colleague, Renee Welsh, MS, RD, LD, for months when Cary was approached in late 2011 by a pharmacist colleague, Jodie Fink, PharmD. In June 2011, the Department of Pharmacy had begun providing one-on-one medication management instruction to Medicare patients with heart failure. Fink soon realized that a group format would allow more patients — including non-Medicare patients — to benefit from this education, so she suggested the concept to Cary. That suggestion was the spark that activated Cary and Welsh’s idea, and the team began presenting trial runs of the class to nurses on Cary’s unit within weeks. In addition to garnering nurses’ support for the class, the trial runs yielded valuable input from nurses for refining content of the class.
Cary says the 30-day all-cause readmission rate for patients with heart failure who completed the class during its first 10 months was 6.9 percent, but no formal comparative analysis with the rate for patients not completing the class has been performed yet. “If nothing else, the class impacts patient satisfaction,” Cary notes. “Most patients leave the class smiling and excited about what they’ve learned. It’s fun to watch their eyes light up when some explanation or example helps them truly understand a concept they didn’t quite get before. That happens often.”
Inpatient group instruction for other conditions: The Case of Lung Transplant
Nurse-led group classes for inpatients with chronic health issues are catching on at Cleveland Clinic for conditions beyond heart failure. The concept took hold recently — albeit without the multidisciplinary twist — to improve education in selfmanagement by patients following lung transplant.
The post-transplant self-management classes are the brainchild of Maria Lamenza, BSN, RN (right), who teaches the classes, and Marie Budev, DO, medical director of Cleveland Clinic’s lung transplant program, which performs more than 100 transplants a year. “At least 70 percent of the success of a lung transplant depends on effective patient education in medication and lifestyle compliance,” says Lamenza, who is the post-transplant coordinator for Cleveland Clinic’s lung transplant unit.
Yet Lamenza was finding that patients often were not awake or alert enough when she would educate them in their rooms. Her suspicions were confirmed when she heard from the outpatient post-transplant coordinators that many patients were coming to them with little retention of what they had been taught in the hospital.
That’s when Lamenza and Dr. Budev decided to supplement the patients’ one-on-one education by “getting patients up and getting them in a room together” for group instruction, Lamenza says. She launched her group classes in June 2012. Classes are held every week in two sessions — two hours (sometimes longer) on Tuesdays and one hour on Thursdays. Tuesday sessions cover information about the post-transplant clinic and outpatient appointments as well as bronchoscopies, graft rejection issues, diet and lifestyle changes, special equipment needed, monitoring tests and similar issues. Thursday sessions are devoted to medications — from anti-rejection meds to anti-infectives — and cover side effects, interactions and the imperative for adherence. Classes are held in a conference room on the nursing unit. Both patients and their family members can attend. Class sizes range from two to 10 people.
After instructing more than 70 patients in group classes, Lamenza saw many benefits reported by Theresa Cary in her heart failure group classes. “Patients really interact and learn from each other,” Lamenza says. “We get very good feedback from patients — they enjoy getting out of their room and talking with others in the same situation.” And the outpatient posttransplant coordinators report that patients now come to their clinic knowing more about their medications and post-transplant issues in general.
Classes can be especially helpful for family members, who often attend when their loved one is still intubated and sedated in the intensive care unit. “Being able to see other patients recovering — including a volunteer who attends most classes and is thriving five years after his own lung transplant — gives them hope,” Lamenza says.
Lamenza plans to start formally measuring the classes’ impact on patient outcomes, but she’s already convinced the classes are worthwhile. “Group instruction helps with retention of information, and that’s critical for these patients.”
Beyond the Call: Volunteer Caregiving
Cleveland Clinic Nurses Seen All Over the World - Click image to enlarge
“I had never traveled outside Ohio before, and here I was going to Uganda,” says Donna Sustar, RN, CNOR, of a volunteer medical mission trip she took to the African nation in 2009. The perioperative nurse educator went as part of a team of Cleveland Clinic volunteers who performed 14 spine surgeries over a two-week period for a population in desperate need of Western surgical expertise. “It was very far away, very primitive and very hard work,” says Sustar, who spent her time doing preoperative assessments and teaching the local nurses. But it was also “a life-changing experience,” Sustar adds. “I learned so much about the human spirit and how strong patients can be. The trip made me understand what nursing is — that it is not defined by high-tech equipment we use but by human touch and its healing powers.”
Donna Sustar, RN, CNOR
Sustar is one of a legion of Cleveland Clinic nurses who volunteer their nursing skills outside the hours of their regular jobs. Many, like Sustar, go on medical missions to underserved areas overseas, from the sugarcane fields of the Dominican Republic to the steep hills of rural India to the bush villages of Liberia. Others volunteer closer to home, running therapeutic horsemanship programs for specialneeds children or providing emergency care after domestic natural disasters or conducting camp physicals for Boy Scout troops. Still others volunteer by providing countless hours of uncompensated time as nursing journal editors, nursing society officers or mentors to nurses in training.
Common threads among nurse volunteers
Talking with nurse volunteers revealed at least three common threads. First, the volunteer experience usually has a big impact on nurses, both personally and professionally. Second, nurse volunteers are typically motivated, as successful professionals, by a desire to give back to the communities that supported them or simply to those less fortunate. Third, when nurses volunteer their time they are most often drawn to the caregiving-related work that comes so naturally to them, although examples of nurses spearheading food drives or fundraisers for nonmedical causes abound as well (see sidebar on page 10). This final thread often stems from nurse volunteers’ desire to share their medical knowledge and expertise.
Cindy Stives, MS, RN, FNP-BC
Such was the case for Cindy Stives, MS, RN, FNP-BC, who volunteers as the court-appointed guardian for Betty, a 97-yearold woman in a nursing home, making healthcare decisions on her behalf, visiting her weekly, taking her home for holiday dinners and generally looking out for her since she was no longer mentally competent and had no living family. Stives volunteers through a local volunteer guardianship program, for which she also serves on the advisory board.
“I got involved when I was looking to do community volunteer work,” explains Stives, who works in Cleveland Clinic’s Department of Long-Term Care overseeing the day-to-day primary care of patients in nursing homes. “I considered a soup kitchen or my church, but then I thought, ‘Why not do something in my field? I provide companionship to patients and make medical decisions for them every day, so why not extend my expertise on a volunteer basis?’” Stives has been an effective advocate for Betty for the last eight years, communicating with the nursing staff at Betty’s facility, making sure she’s clean and her hair gets done, and developing a close relationship with Betty in the process. “Even though she has developed dementia, her face still lights up when I come see her every week.”
Motivations are many
Jeanne Sorrell, PhD, RN
Specific motivations for volunteering one’s nursing skills are as diverse as the volunteers themselves. For Jeanne Sorrell, PhD, RN, who serves as a section editor for two peer-reviewed journals — Journal of Psychosocial Nursing and Mental Health Services and OJIN: Online Journal of Issues in Nursing — a key motivation is her commitment to authorship among nurses. “I feel strongly that nurses should write,” says Sorrell, Senior Nurse Scientist in Cleveland Clinic’s Office of Nursing Research and Innovation. Between the two journals, Sorrell is responsible for writing or inviting eight evidence-based perspectives articles a year. When she invites articles, she turns to nursing colleagues at Cleveland Clinic and across the nation. “When I can help these colleagues write up and publish their work, I feel I’m making a contribution to the profession,” she explains. “And it’s gratifying to see their excitement when they get feedback on their papers from around the world.”
Sorrell is likewise motivated by a commitment to even broader communication by nurses about nursing. “Few people really know what nurses do, so we need to get our voices out there,” she says. “I encourage colleagues to write not just for peer-reviewed journals but for other forums and the general public.” Sorrell herself wrote a play on her own time several years ago based on research she had done on quality-of-life issues in Alzheimer disease. Her play was performed in the community, and she says she embraced this nontraditional format “because I wanted people in the community to learn about what the research showed.”
Audrey Godoy, MSN, RN, CNP
For Audrey Godoy, MSN, RN, CNP, volunteering stems from an even more personal place. Godoy is highly active with the Philippine Nurses Association of America (PNAA), a professional organization of Filipino-American nurses that promotes the professional development of its more than 5,000 members. “The Ohio chapter of PNAA (PNA Ohio) was founded in 1992 by my mother, who is a nurse,” explains Godoy, who works as an interventional cardiology nurse practitioner at Cleveland Clinic. “So I’ve followed in her footsteps to keep PNA Ohio viable and visible, and that’s a lot of what drives me.”
And drive her it does. Godoy says she devotes more than 25 hours a week to her many roles for the organization, which include co-chairing the 2013 PNAA national convention, to be held in Cleveland this summer; co-chairing PNAA’s APN Forum; and serving as immediate past president of PNA Ohio. Her wide-ranging efforts include applying for grants and funding; frequent speaking engagements; and extensive planning, coordination and speaker recruitment for the five-day national convention.
In addition to the familial roots of her volunteerism, Godoy, who was born in the Philippines and raised in the United States, is also motivated by an allegiance to her fellow Filipino Americans. “Through PNA Ohio we provide free community healthcare services and health education to the local Filipino community,” she explains. “I’m eager to share my cardiovascular knowledge in this way because there is a high risk of heart disease among Filipinos.”
Volunteer Caregiving Takes Many Forms
Research for this article unearthed countless ways Cleveland Clinic nurses volunteer their time and talents. Examples ranged from fundraising for no-kill animal shelters (one nurse has spared more than 700 dogs from premature death!) to the efforts of Heart & Vascular Institute nurses to collect 1,400 books for donation to underprivileged children in Cleveland schools and neighborhoods. Choosing just a handful of examples to spotlight was a challenge, so we focused on volunteer efforts directly related to caregiving or advancing the nursing profession.
Yet even some examples not directly linked to nursing care circle back to the caregiving that’s at the core of the nursing ethic. Take the case of a group of current and retired Cleveland Clinic nurses who met monthly in 2012 at the house of Mary Beth Modic, MSN, RN, CNS, CDE, to reconnect with one another and sew fleece blankets for the largest men’s homeless shelter in Ohio. The effort became contagious, expanding to professional organizations to which Cleveland Clinic nurses belonged. Nurses from nine Northeast Ohio hospitals in Cleveland Clinic health system were recruited and enthusiastically participated, enabling the group to donate more than 300 blankets to the shelter just before the winter of 2012-2013 set in.
“Florence Nightingale spoke of the environment as being critical to the prevention and eradication of disease,” says Modic. “She described the importance of light, warmth, air and sanitation to the health and well-being of the indigent of London. In the same tradition, our blankets are giving the men at this shelter, who usually must leave the shelter after four days, some means of warmth and protection from hypothermia. We do not need to travel far to impact the lives of those who are overlooked.”
Volunteerism builds better nurses
Beyond common threads in their motivations, many nurse volunteers consistently cited a shared sense of reward from their volunteer work. “As much as I helped in Uganda,” says Sustar, “they helped me too. I wasn’t prepared for how much I would learn there.”
One of Sustar’s most important lessons was that “you don’t need language to connect to your patients,” she says. “I learned how much you can connect through eye contact, smiles and touch. I found that if you don’t know what to say, it’s OK to not say anything and to just be there for your patient.” She says she’s now better able to be “100 percent present with” her patients in her daily practice back home.
Ken Eckberg, BSN, RN
Ken Eckberg, BSN, RN, says he’s benefited in similar ways from the six medical mission trips he’s made to Haiti since March 2010 to run free primary care clinics and provide education on hygiene, family planning, nutrition and other preventive care. “The culture in Haiti is very different, so there’s no point in trying to blend in with it,” explains Eckberg, a staff nurse on an internal medicine unit on Cleveland Clinic’s main campus. “So I had to become more culturally competent and overcome language barriers and barriers to understanding in order to see where patients’ health-related beliefs were coming from and how best to provide the care they needed.”
For example, when offering HIV education, Eckberg learned that many Haitians feared they could catch the virus from strong winds or haircuts. While he thinks he helped dispel the misinformation about wind-based HIV transmission, Eckberg found that the haircut-related fears were more understandable when he learned that Haitians often use razors to cut hair. “I didn’t understand that about the culture at first, but as I learned more I was better able to counsel people about their real and perceived risks,” he says. Eckberg adds that he’s applied these lessons when caring for patients from other cultures back home.
Erica Vergara, BSN, RN
Erica Vergara, BSN, RN, an emergency department nurse at Cleveland Clinic Florida, says her two medical mission trips to Haiti in 2011 seared into her consciousness the importance of The Joint Commission’s strict core measures for pneumonia management. “I will never forget a 34-yearold man who came to the Port-au-Prince hospital where I was volunteering with the most severe pneumonia I’ve ever seen,” Vergara recounts. “He self-extubated and quickly died of respiratory arrest because we ran out of appropriate sedatives. Watching a patient die because he simply couldn’t breathe has made The Joint Commission’s pneumonia core measures relevant and real for me like nothing else could. I use these core measures every day in my practice, and now I really feel their importance.”
For Sorrell, volunteering her time as a journal editor has enriched her by keeping her on top of the issues in her field. “It’s made me delve into subjects I wouldn’t have otherwise, and that’s taught me a lot,” she says. “Right now I don’t know much about changes in the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but I will in a few weeks once I do research on it for an upcoming journal column.”
Beyond the payoffs in improved practice, volunteering almost inevitably enriches nurses on a personal level as well. “I’ve made friends in Haiti whom I now communicate with on Facebook,” says Eckberg. “Every time I go back to Haiti, things seem to be getting better. It feels good to see those changes the Haitians are making for themselves.” Stives shares similar sentiments. “The feeling of reward I get from volunteering as Betty’s guardian is better than any paycheck I’ll ever receive,” she says.
Institutional support matters
Another commonality among nurse volunteers is that almost all of them feel supported and encouraged in their volunteer work by their managers and co-workers. Many are grateful for flexibility in scheduling to help accommodate medical mission trips or attendance at volunteer groups’ board meetings. “My managers and co-workers supported me 100 percent when I went to Uganda,” Sustar says. “I felt so much encouragement from Cleveland Clinic to go out and make a difference.”
Sorrell notes that whereas some employers might view her volunteer editorial work as “moonlighting,” her department encourages it. “It’s nice that they urge us to expand our roles in these ways,” she says.
Eckberg says this support extends to his co-workers as well. “When I go to Haiti, I always put a box in the break room and ask for supplies — toothpaste, vitamins, over-thecounter medicines. It always fills up quickly with donations from co-workers. And when I come back, everyone wants to see photos and hear what happened.”
For Vergara, the interest has gone even further. “On my second trip to Haiti, I convinced two of my co-workers to come with me,” she says. “I think volunteering is contagious.”
Empowerment Through Exposure to Nursing
During a recent patient discharge, Crystal Copley, RN, noticed a skeptical look on her 60-year-old male patient’s face. He had entered the telemetry unit at Cleveland Clinic’s Medina Hospital four hours earlier, complaining of intermittent chest pain. The physician ordered an outpatient heart catheterization.
“As I educated the patient during discharge, I was concerned he might not follow up with the heart cath,” says Copley. “After some inquiry to prompt the patient to express his concerns, I learned he’d had bad experiences with past physicians, which led him to avoid routine medical attention.” She assured the man about the attending physician’s skills and bedside manner. Comforted, the patient and his wife promised Copley they would follow through with the heart catheterization.
The importance of taking time to connect with patients was stressed to Copley at a Nursing Grand Rounds presentation on relationship-based care by Marie Manthey, MNA, FRCN, FAAN, in May 2012. “Manthey’s presentation inspired me to provide the best care possible to my patients, even under tough situations such as staffing shortages,” says Copley. “I knew that relationship-based care was important, but I don’t think it clicks until you actually hear how it makes a difference. Now I make a conscious effort to develop relationships with every patient and family member.”
A trio of thought leaders
“I’m proud of all the professional development we offer at Cleveland Clinic, but we can’t just hear the echo of our own voice,” says Joan Kavanagh, MSN, RN, Associate Chief Nursing Officer, Clinical Education and Professional Practice Development. “We absolutely have to bring in thought leaders from the outside.” In 2012, three such leaders provided insight at the health system’s Nursing Grand Rounds:
Susan K. Baker, MHA, presented ways to improve the patient care experience by identifying patient expectations and responding to them. Baker is an expert on service quality, risk management, patient satisfaction and patient relations.
Theresa Brown, BSN, RN, shared her experiences and insight on safety issues and the public perception of bedside nurses. Brown, who also holds a PhD in English, practices as a bedside nurse in medical oncology and has written columns and blogged for The New York Times and other national media.
Marie Manthey, MNA, FR CN, FAAN, spoke about the three R’s of relationship-based care: roles, relationships and resources. Manthey has been a force in nursing since the late 1960s, working for decades in hospitals and as a consultant. Her theories on relationship-based care are a primary tenet of the Zielony Nursing Institute’s Professional Practice Model.
Giving voice to the Professional Practice Model
Cleveland Clinic hosts monthly Nursing Grand Rounds to advance knowledge related to innovative, evidence-based nursing practice that promotes collaborative, quality care. Internal and external experts provide one-hour presentations at the health system’s main campus on a variety of topics. Last year, those ranged from chronic kidney disease to pain management. Three sessions were led by renowned national nursing thought leaders — the aforementioned Marie Manthey plus author and columnist Theresa Brown, BSN, RN, and healthcare customer service expert Susan Baker, MHA (see sidebar for more on their talks).
“We want to be global leaders in the professional practice of nursing,” says Joan Kavanagh, MSN, RN, Associate Chief Nursing Officer, Clinical Education and Professional Practice Development. “Nursing Grand Rounds supports that mission and reflects our commitment to our Professional Practice Model.” That model encourages nurses in Cleveland Clinic’s Zielony Nursing Institute to provide relationship- based care, demonstrate thinking in action and act as serving leaders. “A model can seem abstract,” Kavanagh notes. “Bringing seminal speakers here to talk gives voice to our Professional Practice Model and brings it to life.”
Fueling enthusiasm for the profession
The model was brought to life for Marlene Franz, BSN, RN, at the Nursing Grand Rounds presentation by Susan Baker last December. Baker discussed the importance of customer service and maintaining a positive, friendly attitude with patients. She shared the significance of greeting patients, describing their plan of care and explaining procedures.
“Baker reinforced everything we learn in nursing school, but she did it in a way that made it really meaningful,” says Franz, who worked in orthopaedics before transferring to an observation unit several months ago. The 40-year nursing veteran ends her shifts by saying goodbye to all her patients. “There’s always something patients need, be it pain meds or water,” she says. “Even when I want to go home at the end of a long shift, it’s important to connect once more and say goodbye. Baker’s presentation reassured me that I’m doing the right thing.”
Franz attends all the Nursing Grand Rounds. Aside from affirming her practice, the presentations help Franz keep up to date on nursing trends and remain enthusiastic about her profession. “I don’t subscribe to nursing magazines or journals, so I appreciate the opportunity to hear experts at my workplace,” she says. “These are renowned speakers who come to Cleveland Clinic. I am awed by them!”
That is the goal, explains Christina Shane, MSN, RN, a clinical nurse specialist in the Office of Nursing Education and Professional Practice Development and former Nursing Grand Rounds co-chair, along with Catherine Skowronsky, MSN, RN, ACNS, CMSRN. “This is an excellent forum for nurses to share changes in nursing practice rather than just focus on advances in technology,” Shane says.
Huge budgets not necessary
Approximately 60 to 100 nurses attend the sessions each month. Presentations are also teleconferenced to Cleveland Clinic’s community hospitals and family health centers throughout Northeast Ohio and to Cleveland Clinic Florida. Nurses can claim one CNE contact hour per session. Speakers are chosen by the Nursing Grand Rounds Committee in collaboration with the Nursing Quality Department, clinical nurse specialists and other Zielony Nursing Institute stakeholders.
The committee works diligently to bring in national thought leaders. Prior to 2012, speakers included leading nursing theorists Patricia Benner, PhD, RN, FAAN, and Jean Watson, PhD, RN, AHN-BC, FAAN. Although the names are big, the committee’s budget is not: Most outside speakers receive a small honorarium plus travel expenses.
“That speaks to the level of professionalism of these experts,” says Kavanagh. “It doesn’t take a million dollars to bring in fabulous speakers. They are truly interested in connecting and sharing. We’re all on a journey, and nursing leaders want to hear about the journey of others.”
Elevating everyone’s practice
Kathy Burns, MSN, RN, ACNS-BC, CEN, says her journey has been enhanced by Nursing Grand Rounds. “We were able to take ideas and figure out how to make them work here at Medina Hospital,” says Burns, a clinical nurse specialist at the community hospital. One pearl she took away from last fall’s presentation by Theresa Brown was the vital connection between bedside handoff communications and patient safety. Burns is now working with the hospital’s Nurse Practice Council to improve bedside handoffs.
Burns, who serves as the Nursing Grand Rounds facilitator at Medina Hospital, promotes events to nursing staff. Videos of the presentations are available online for nurses who could not attend. Burns showed the Manthey presentation at a Nurse Practice Council meeting.
Linnea VanBlarcum, MSN, RN, ACNS-BC, who works in Patient Care Services at Cleveland Clinic’s Lutheran Hospital, promotes Nursing Grand Rounds to nurses there. Watching the Manthey presentation via teleconference brought back memories for VanBlarcum, who participated in a brown-bag lunch with the nursing guru while attending graduate school years ago. “The impact that interacting with somebody like Marie Manthey can have is amazing,” she says.
VanBlarcum encourages staff to attend the presentations by using email blasts and enlisting the support of nurse managers. She believes participating in Nursing Grand Rounds can help nurses shift their focus from daily tasks to the big picture. “Many nurses focus on tasks — getting baths done, passing meds, changing dressings,” she says. “We need to take it a step beyond and look at the total picture: not only what I need to accomplish, but what I need to help the patient accomplish.”
Manthey, Brown, Baker and other thought leaders who have participated in Cleveland Clinic’s Nursing Grand Rounds would certainly agree. And sharing such ideas is beneficial for everyone. Says Kavanagh, “Together, we’re all growing and improving our practice.”
Close Observation Unit Yields Triple Bottom Line: Safer Patients, Lower Costs, Heightened Satisfaction
High-acuity medical inpatients who exhibit disruptive behavior due to delirium, dementia and unmanaged psychiatric disorders present unique challenges for care teams and nurse managers. “Patients with these qualities have impaired judgment and can’t follow directions for their safety,” says Cleveland Clinic clinical nurse specialist Catherine Skowronsky, MSN, RN, ACNS, CMSRN. “Patients may try to climb out of bed unassisted, which puts them at risk for falls. They disrupt therapy by pulling out IV lines, oxygen and tracheostomy tubes. Restraints pose another safety risk.”
Since patients with disruptive behaviors are dispersed throughout a medical floor, their demands on nursing attention can disrupt the flow of the unit. Nursing staff are concerned that they lack specialized training and resources necessary to provide optimal patient care. Oneto- one observation can be provided through patient care companions (PCCs), but PCCs provide unskilled care that is costly and does not necessarily prevent adverse events such as falls. Plus, PCCs are not always available. “We knew there had to be a better way,” Skowronsky says.
Keys to Success, Lessons Learned
Since the close observation unit (COU) opened, the nurse management team has discovered some best practices that have contributed to its success:
Stay firm on staffing. The one RN/one CT staffing level must be maintained consistently for the approach to work. “Early on, when all four beds weren’t filled at night or when staffing was short, there was a temptation to give the COU nurse one more patient outside the unit,” says Maureen Palmer, MBA, BSN, RN, CRRN, NEA-BC. “It was too tough on the nurse, there was too much on the CT’s shoulders and the nurse couldn’t keep a close eye on patients.”
Be prepared to meet the demand for the COU beds. The COU is essentially always at capacity, and patients can be admitted from several different units. Decisions about whether a patient should be admitted to the COU are nurse-driven and based on established admission criteria and rule-out criteria. “We make it clear that medical staff can request a bed in the COU,” says Palmer, “but the decisions are nurse-driven.”
Strongly monitor the criteria for discharge so that beds are available when needed. These criteria include demonstration of reduced agitation, increased cognition and ability to follow directions, as well as freedom from the need for restraints. Additional discharge criteria are expression of suicidal thoughts or the need for isolation.
So a multidisciplinary Cleveland Clinic team with members from nursing, psychiatry, medicine and social work set out to assess the requirements of caring for these special-needs patients as well as to address caregiver stress and operational and cost issues. The result was the creation of a four-bed close observation unit (COU) with dedicated staff and coordinated care specifically for patients exhibiting disruptive behaviors. The COU was opened in May 2011 within a 36-bed high-acuity medicine unit on Cleveland Clinic’s main campus. Since the COU opened, patient safety has been enhanced, costs of care have decreased (due to reduced need for PCCs), and nurses believe that both patients and their families are more satisfied.
Design and staffing considerations
Many of the COU’s virtues lie in the simplicity of its design. Walls were knocked out between two semiprivate rooms that had been connected by doorways, and two windows were added that are large enough to allow observation of all four patients simultaneously (see photo on page 1). “Every bed can be seen from anywhere in the room,” Skowronsky says. Patients of both sexes are accepted, with privacy curtains used when needed. Total construction costs were about $19,000.
The COU is always staffed by an RN; the nurse-to-patient ratio remains consistent with the rest of the unit at 1:4, but the COU’s setup allows the nurse to continuously monitor all four patients. In addition, a clinical technician (CT), who can perform phlebotomy and sterile techniques, is always dedicated to the four-patient COU. The CT carries out the roles of a PCC and a patient care nursing assistant (PCNA). All CTs were previously PCNAs on the unit. They volunteered to work in the COU and received additional training for their higher-level roles.
The COU’s thoughtful design makes it part treatment area and part nurses’ station, helping to ensure that two caregivers are able to stay in the room continuously. For example, the unit contains two computer desks with sconces on walls right next to the computers so the staff can work at night without disturbing patients.
Early gains in caregiver satisfaction
“Gains in nurse satisfaction were pretty immediate,” says nurse manager Brigitte Folds, BSN, RN. “We saw improved satisfaction among nurses who volunteered to take care of patients in the COU and among other nurses on the unit, who no longer need to care for patients exhibiting disruptive behaviors.”
Bridget McEndree, RN, volunteered to work in the COU when it first opened, and she’s never looked back. “It can be challenging, but at the same time it has benefits,” McEndree says. “You’re there when the doctors come in on rounds and you hear everything, so you learn a lot more about patients.” She also values the close working relationship with the CTs.
Training has been a key aspect leading to support of the initiative. “Strong education for the caregiving team assigned to the COU was pivotal to its success,” says Maureen Palmer, MBA, BSN, RN, CRRN, NEA-BC, who was Clinical Director for Medicine at the time the unit was built. All RNs and CTs working in the COU go through the Nonabusive Psychological and Physical Intervention (NAPPI) course on safety and relationship building.
Patient engagement, multidisciplinary collaboration
The close observation environment allows for greater patient engagement, including use of distraction methods such as art therapy and washcloth folding and the ability to provide more attention that calms patients and often eliminates the need for restraints, Skowronsky says.
Patients in the COU benefit from an interdisciplinary approach to care. A psychiatrist and social worker round daily on COU patients with a history of psychological illness, and a clinical nurse specialist also rounds to identify nursing interventions for dementia or delirium.
“The COU allows patients with medically complex issues and behavioral disorders to be in a much friendlier environment while remaining under the care of the primary medicine team,” says psychiatrist Leo Pozuelo, MD, who helped develop the COU and leads the psychiatric consultation team. “The nursing staff is empowered to put the right patients in the right place.”
The COU has achieved a number of important outcomes, including:
Increased patient safety. In a recent quality initiative, patient fall rates in the COU and the rest of the unit were statistically similar even though COU patients trended toward being older and were significantly more likely to have neurological and psychiatric diagnoses, placing them at higher risk for falls than the average patient outside the COU. “We believe the higher caregiver-to-patient ratio in the COU, particularly for the unlicensed nursing staff, is what accounts for this finding,” says Skowronsky. In addition, none of the patients who fell when in the COU during the one-year study period were injured.
Decreased cost due to decreased use of PCCs. Companion use has declined by more than half, which saves costs, even after factoring in training costs and CT care.
Increased patient satisfaction scores for the nursing unit. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores increased beyond the 90th percentile since the COU opened. Families expressed their happiness with care in the COU, Folds says. Family members who typically might have stayed at the patient’s bedside around the clock are now leaving to go home and rest, knowing that their loved one is being very closely monitored.
Increased nurse/caregiver satisfaction. Employee engagement scores increased across the unit since the COU opened.
Breaking new ground
The COU is the only unit of its type at Cleveland Clinic, but other medical floors and specialty units are considering replicating the concept, Folds says. The unit’s unique design has also drawn teams from other health systems to visit Cleveland Clinic to learn about the COU firsthand as they explore implementing a similar unit themselves. “No one else seems to have anything like it,” Skowronsky says.
Crisis Nurses Form Crisis Response Team to Improve Management of Suicidal Patients in Rural Setting
A small group of nurses in a rural health clinic turned confusion about managing suicidal patients into a comprehensive, transferable plan for responding to patient crises and making appropriate referrals.
In October 2011, a young woman presented to Cleveland Clinic Wooster Women’s Health Center with suicidal thoughts. The visit served as a wake-up call to nurses at the center, located about 50 miles southwest of Cleveland. They needed a plan for managing suicidal and depressed patients in their rural setting that has few identified psychiatrists and psychologists. “The visit was chaotic,” recalls Joy Blough, LPN. “We had two nurses calling the same referral location and being told two different things. Many nurses were circulating around the patient. Everyone wanted to help, but there was confusion and a lack of confidence among nurses about what to do. We needed a more streamlined approach.”
‘Next time will be different’
Although suicide was prevented and the patient is feeling better now, Blough and a small team of other nurses at Wooster Women’s Health Center decided they needed to be more prepared for the next visit from this type of psychologically fragile patient. They formed a crisis response team (CRT) and identified their needs, which were for:
- Education on how to assess the risk level of a depressed or suicidal patient
- Information on ways to maintain safety for staff, the depressed/suicidal patient and other patients
- Direction on where to refer depressed or suicidal patients according to their risk (low, medium, high)
Kimberly Beckler, LPN, and Terrie Koch, RN
As the team searched the literature for suicide prevention strategies, “it became apparent that screening alone would not significantly lower suicide rates,” says CRT member Terrie Koch, RN. Drawing on evidence and recommendations that supported coordination among providers of community resources and preventive services, the CRT consulted closely with members of a local county- based suicide prevention coalition comprising a wide range of mental health and related agencies from across the community. The team sent a representative to the coalition’s monthly meetings for more than a year and solicited input on a CRT binder to serve as a reference tool and action plan for managing depressed/suicidal patients.
The response plan at a glance
The CRT — whose core members are Blough, Koch and Kimberly Beckler, LPN — began meeting biweekly in January 2012 to develop the evidence-based binder and management plan. Sources of the plan included key research reports from the medical literature and input from suicide coalition partners. The binder contains the following materials to increase nurses’ confidence and comfort in responding to a suicidal or depressed patient in crisis:
- An overview of warning signs of suicidal behavior
- An outline of three recommended nursing roles during a crisis (see below)
- A step-by-step response plan to follow, including a flowchart for referral instructions
- Situation-specific handouts covering local resources and referrals
- Directions for using a customized SmartSet, a group of common orders that can be deployed in the electronic medical record to fill in templates for notes and patient instructions
- A crisis event survey to be completed by nurses and other providers after the event (survey input helps the CRT improve the binder or process as needed)
Several CRT members attended an in-service by a local mental health counseling center on safety in the office setting for patients with suicidal thoughts. The in-service prompted the CRT to enlist maintenance staff to convert four exam rooms into “safe rooms” by removing or securing office equipment that could be used for self-harm.
Additionally, a local mental health foundation provided a grant to train a psychologist and social worker at Wooster Women’s Health Center in the QPR method of assessment, a simple three-step approach for recognizing suicide warning signs by appropriately questioning, persuading and then referring the patient to someone who can help. The psychologist and social worker then trained CRT members and others at Cleveland Clinic’s Wooster Family Health Center — 50 staff members in total — in the QPR method.
An important part of the response plan is the division of key responsibilities into three distinct nursing roles:
A patient contact nurse, who stays with the patient to ensure safety until a mental health provider arrives to assess the patient
A phone contact nurse, who follows the binder’s referral flowchart and serves as the sole person making calls
A circulating nurse, who is free to move about and assist the other nurses as needed
Although fulfilling these functions is important, Blough and Koch emphasize that the model is highly transferable and fairly adaptable. “This approach can be used anywhere in the clinic,” says Blough. “Our plan is laid out so simply that it’s not essential that RNs or LPNs fulfill these roles; medical assistants and others can be guided by information in the binder. Having three staff members perform the functions is ideal, but the model can be carried out by two people.”
Results: Broader referral pool, smoother crisis visits
Before the CRT was formed, Wooster Women’s Health Center staff were aware of only nine providers or facilities to refer suicidal patients to for counseling and treatment. In the year after the CRT’s formation, that number more than doubled — to 21 — as a result of CRT efforts to identify more local referral resources.
Since the initial chaotic patient visit in October 2011, the center has had two more visits involving suicidal patients who required a crisis response. The staff’s self-ratings on the binder’s crisis event survey improved dramatically for these two visits compared to the October 2011 visit across all eight measures assessed, which ranged from how well safety concerns were addressed to the timeliness of referral appointment scheduling. “The process seems to be working,” says Blough. “We went from the confusion of the first visit to high ratings across all measures in the third visit, where a counselor from our local counseling center actually came to our office to help the patient right then and there.” The CRT is exploring having the crisis response process evaluated by the outside providers to whom patients are referred.
Next steps and advice
CRT efforts are yielding ancillary benefits as well. The CRT binder has been copied and distributed to other departments at Wooster Family Health Center and to the Nurse On Call telephone service. “It’s easily transferable,” says Blough. “We’re already adapting the binder for our pediatrics practices to make it more specific to pediatric patients.” Blough says she refers to the binder often, including for patients who are not suicidal but may need some general counseling.
CRT members are developing a new section of the binder to include an action plan, referral information and patient handouts for another group of patients in crisis — domestic violence victims.
Koch sees the CRT’s approach as highly applicable, especially to clinics in rural settings. She says integration of the approach with local community resources is essential to success. “We developed a strong relationship with our community organizations; we integrated into them, and they integrated into our project too,” Koch says. “My advice to others is to know your community resources. If you don’t have a local suicide coalition, create one. In one study, investigators found that up to 80 percent of suicide attempters said their attempt could have been prevented. That underscores the need to educate and empower nurses and other clinic staff in suicide assessment and referral.”
Simple 'Flip Flag' Initiative Boosts Pain Identification and Reassessment
The orthopaedic unit of a Cleveland Clinic community hospital achieved a substantial increase in documentation of pain reassessment after installing inexpensive “flip flags” outside patient rooms as visual cues to monitor patient pain.
When staff on the 16-bed orthopaedic unit at Cleveland Clinic’s Lakewood Hospital learned from chart audits that only 57 percent of pain interventions among its patients were followed by pain reassessment within one hour, nurse managers were determined to boost that rate. After all, pain reassessment is a vital part of successful pain management in hospitalized patients and a basic patient right. Also, documentation of pain reassessment within one hour of pain intervention is a Joint Commission requirement.
“Audits showed that we weren’t meeting our patients’ needs for pain reassessment,” says Jennifer Van Dyk, MSN, RN, who was the unit’s nurse manager at the time. “When you’re not consistently reassessing pain, you cannot know whether your pain management efforts are working.”
So Van Dyk searched the medical literature for interventions to raise pain reassessment rates on her unit at the community- based acute care hospital. Although she did not find any evidence-based examples directly addressing her unit’s needs, she came across reports of the use of flags outside patient rooms for other purposes (such as to remind nurses about wait times) and decided to adapt the idea. So Van Dyk worked with her assistant nurse manager, Bethany Farrell, BSN, RN, to develop a flag-based reminder system to prompt timely and more universal pain reassessment.
How it works
Red and yellow flip flags — plastic flags similar to those outside doctor’s office exam rooms — were installed on the door frames of the unit’s 16 patient rooms. When any caregiver enters a room and learns that a patient is in pain, the caregiver flips up the yellow flag — which signals to the nurse caring for the patient that pain assessment is needed — in addition to verbally informing the nurse that the patient requires assessment.
When nurses enter patients’ rooms, they flip down the yellow flags to indicate that pain is being assessed and then proceed to perform pain assessments. If any type of pain intervention is needed — from a behavioral intervention, such as repositioning the patient, to administering pain medication — nurses provide it and then flip up the red flags, which indicate that pain reassessment is needed within the next hour. Once reassessment takes place and pain scores are documented, nurses flip down the red flags again. Because the unit’s nursing staff do hourly rounding, a timer is not needed to ensure reassessment within the hour.
“Since nurses have so many competing demands, we intended the flags as an easy visual reminder to ensure that pain identification and reassessment are not forgotten,” explains Van Dyk. And the project was inexpensive to implement, with unit flags costing about $250 in total.
Results and ripple effects
The initiative appears to be working. In the first three months after the flags were installed in August 2012, chart audits showed that pain reassessments were documented within one hour of pain intervention 91 percent, 88 percent and 94 percent of the time — considerably higher than the 57 percent pre-implementation rate.
“We thought the flag flipping might be viewed as yet another task, but the nurses found it easy to do and very useful right away,” says Van Dyk. “They wanted to improve pain management and reassessment on the unit — it was a real concern of theirs — so they’ve approached the flip flags as a tool to help them do so.”
“The patient care nursing assistants (PCNAs) are also now more aware of pain as an issue for our patients and have taken more initiative to ask patients about pain when they interact with them,” adds Farrell. In fact, it was a nursing assistant — Jackeline Colón-Bracero, PCNA — who suggested that one of the flag colors be used to signal that a patient was in pain, as the nurse managers’ initial idea was to use just one flag color, and to use it solely to indicate the need for reassessment.
Other inpatient units at Lakewood Hospital plan to implement the flip-flag program for pain reassessment throughout 2013. If the chart audit-based reassessment data continue to be favorable, more robust data collection in an IRB-approved study may follow, perhaps to assess the initiative’s effect on patient satisfaction scores. Farrell says the unit’s HCAHPS pain management scores have been on the rise since the flags were installed, although correlation remains speculative at this point. In the meantime, she says the initiative has “made caregivers at every level on the unit much more aware of how important pain assessment and reassessment are, and we know this makes a difference to patients.”
What advice does the team have to share? “The idea of starting another initiative can be overwhelming to nurse managers, who already have so many projects to juggle,” says Van Dyk. “But if you have a real need and a project strikes you as having real potential to work, then try it. Don’t be afraid to fail — just develop it in a way that ensures the input and involvement of your staff from the grass roots.”
Keep the Pressure On: Nurse-Led Program Centered on IPC Devices Raises Awareness and Adherence
When Mary Lou Friedrich, MSN, RN, walked into patient rooms on a neurological medical-surgical unit at Cleveland Clinic’s main campus a year or two ago, she often saw intermittent pneumatic compression (IPC) device sleeves draped over beds. Friedrich, a clinical instructor, understood the importance of IPC devices as first-line prevention against venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism. Because postoperative patients on this 50-bed unit could not always be safely anticoagulated, use of IPC devices was critical.
“Correct IPC use wasn’t continuously on the nursing staff’s radar,” says Friedrich. “They didn’t know some of the facts and details that make it so important.” A prevalence study conducted on a variety of surgical units on Cleveland Clinic’s main campus in December 2011 confirmed what Friedrich witnessed: Only 25 percent of 431 patients observed in beds or chairs were wearing IPC devices as ordered. Those findings prompted a nurse-led performance improvement initiative.
In March 2012, the Zielony Nursing Institute’s Department of Nursing Quality rolled out a pilot program, dubbed “Keep the Pressure On,” to underscore the importance of appropriate IPC device use to nursing staff, physicians, ancillary providers, patients and families. The Nursing Quality Department formed a VTE Committee and teamed with representatives from other relevant Cleveland Clinic entities, including the Neurological Institute and the Section of Vascular Medicine, to create the Keep the Pressure On program.
Baseline barriers to IPC use
“VTE prevention has been an ongoing concern for patient safety and outcomes,” says Stacey Claus, MSN, RN, GCNSBC, CNRN, a clinical nurse specialist who worked on the med-surg unit in 2012. Claus was a member of other committees concerned with VTE, and she suggested the unit for the pilot program. Nurse manager Dannelly Perdion, BSN, RN, agreed: “Our patients are at risk for VTE because of the operations they undergo,” Perdion says. “IPC is the only prophylaxis that can be used for many patients because of the risk of bleeding.”
To kick off the pilot program, a baseline audit of IPC device use on the med-surg unit was conducted, revealing a 33 percent adherence rate. In addition, the unit’s nursing staff completed an online survey to gauge their knowledge of VTE risk factors, prevention and treatment as well as barriers to IPC device use and patient education resources. The survey identified four primary barriers to IPC device use:
- Misconceptions about use
- Patient refusal
- Pump and sleeve availability
- Removal by others
“The biggest eye-opener was the lack of understanding about how long IPC devices must be worn to be most effective,” says Perdion. “Nursing staff had preconceived notions that if patients were sitting in chairs or walked around a bit, they didn’t need to wear the sleeves.” In addition, if patients declined to wear the devices, some nurses simply made a note in the chart rather than explain the potential consequences of not wearing the IPC device.
Equipment availability was also a challenge. The device consists of a disposable sleeve that is wrapped around the calf and connected with tubing to a pump that inflates and deflates the sleeve automatically to mimic the effect of ambulation on blood flow. Nurses reported that pumps often were missing from patient rooms and that sleeves and tubing weren’t in supply stations.
Moreover, sleeves were frequently removed from patients by others, such as family members and other providers who sometimes forgot to put the devices back on. “Caregivers are so focused on making sure they get everything done for patients that things like IPC devices may get neglected,” says Perdion. “But we need to remember that these little things can make the biggest difference in outcomes.”
Creating educational tools
Based on the survey and prevalence study, the VTE Committee developed mandatory education for caregivers on the medsurg unit. Friedrich gave in-service presentations in May and June 2012 on the importance of adhering to IPC orders, risk factors for VTE, myths and facts about IPC devices, and more. Data from the prevalence study on the unit were also included. “When you show people data pertinent to them, their ears perk up,” says Friedrich. “We made it personal for them.”
As part of the pilot program, the VTE Committee teamed with the Department of Clinical Engineering to ensure that pumps, sleeves and tubing were readily available. A department representative rounded each morning to ensure that pumps were on all 50 beds.
The VTE Committee also created an electronic medical record template for documenting patient refusal to wear the devices, instructed nursing staff on educating patients about the significance of IPC adherence, and developed educational fliers to be placed in admission packets and other patient resources. Additionally, signs were posted above whiteboards in patient rooms reminding patients to wear the sleeves and “Keep the Pressure On.”
A turnaround in adherence
Starting in July 2012, Claus and Friedrich began conducting twice-weekly adherence audits to observe whether patients were wearing IPC devices, ask patients if they knew why and review IPC documentation. The audits provided a great opportunity for Claus and Friedrich to mentor nursing staff.
For instance, when rounding with a nurse, Claus discovered a patient with Parkinson disease sitting in a chair without his IPC device. When she asked why, the patient said the sleeves were hot and uncomfortable. She empathized with him, then reiterated the reasons for the IPC device and presented an option: Claus would add a stockinette, a soft cotton sleeve, under the compression stocking to alleviate heat and skin irritation. The patient agreed. “The conversation only took a few minutes,” says Claus, “and he was happy to try out the solution.”
By August 2012, the med-surg unit’s adherence rate rose to 69 percent — nine points higher than the program’s goal of 60 percent. Now the unit conducts monthly audits. Cleveland Clinic has since instituted the Keep the Pressure On program on all surgical units at its main campus and at two of its community hospitals. It plans to expand the program to its remaining community hospitals based on VTE rates.
“It’s a great program,” says Perdion. “It has made a difference in awareness of the importance of IPC devices, and we’re providing better care because of it.”