Notable Nursing: Update January 2013

Featured Stories

Recording Vital Signs Streamlined with MP3 Players

Last October, PCNAs on two units at Cleveland Clinic’s main campus participated in a pilot program using MP3 digital audio players to record patients’ vital signs. The Mobile Vital Signs Pilot was initiated by the Nursing Informatics Department, which asked PCNAs what type of technology would aid them in patient care.

“They very quickly said that a small device they could keep in their pockets and use to collect vital signs would save them time,” says Marianela Zytkowski, MS, BSN, RN-BC, DNP, Associate Chief Nursing Officer for Nursing Informatics.

PCNAs expressed concern that mobile workstations often were unavailable to record temperature, blood pressure, respiration rate and pulse. “They were left writing all of their documentation down and waiting for a device to be free or going back to the nursing station and hoping for a free computer,” says Zytkowski. That led to delays getting information into the electronic medical record (EMR) and greater potential for transcription errors.

Leveraging existing technology, the Medical Operations Department took a mobile application it had created for physicians to use on the iPad and modified it for the MP3 player. Six devices were piloted during day shifts for two weeks on two units – one a general medical-surgical unit and the other a colorectal surgery unit. Pre-pilot data collection occurred during the first week to gather baseline information, such as the average time it took for vital signs to be recorded.

The following week, PCNAs used the MP3s at the bedside. They accessed patients’ medical records on the devices, took vital signs and then entered the information, which was transmitted wirelessly to the EMR. The application also featured built-in clinical support. For example, PCNAs were alerted if a vital sign was more or less than 10 percent of the last value recorded.

While the Nursing Informatics Department is currently compiling a full report on the results of the pilot, it cited several improvements. Staff transcription time for collection of vital signs’ information and entry into the EMR decreased significantly from an average of almost 19 minutes prior to using the devices to just one and a half minutes with the electronic device. In addition, there was improved accuracy and detail and immediate communication of patient information between nurses and PCNAs.

Nursing Informatics plans to roll out the next phase of the pilot this month to two units serving different populations. Based on feedback, additional features may be added, such as the ability to record patient intake and output and view diet orders.

Specialty Certification Helps Nurse Provide Holistic Care

Madeline Gronsky, ADN, RN, PCCN, believes she can better serve her patients in the cardiac open heart post-operative unit at Cleveland Clinic thanks to her specialty certification. Recently, a patient had elevated hemoglobin A1C levels. “I knew right away that he was probably diabetic and that was contributing to a lot of his cardiac issues,” says Gronsky. “The certification gives me a broader outlook, whether it’s endocrine or gastrointestinal. I don’t just look at issues specific to cardiac care.”

Gronsky was first certified as a Progressive Care Certified Nurse in 2006, two years after the American Association of Critical-Care Nurses began offering the certification to nurses who care for acutely ill adult patients. She has been re-certified twice, most recently in 2012. “Certification fits in with the Zielony Nursing Institute Professional Practice Model,” says Gronsky. “Nurses need to be experts at what they do in order to provide relationship-based care. Having that certification supports your knowledge base.”

Gronsky was among the first nurses to take the combined PCCN/CCRN review course at Cleveland Clinic for progressive care and critical care certification. Offered twice a year, the two-day class covers cardiovascular, pulmonary, neurology, renal, endocrine, gastrointestinal and multisystem topics. It’s taught by certified ICU and step-down clinical nurse specialists. Last year, more than 160 nurses enrolled in the course, though not all chose to take the certification exams. In 2011, Cleveland Clinic’s main campus had 21 PCCNs and 141 CCRNs, a 25 percent increase from 2010.

“Certification has been shown to keep patients safer, improve outcomes and enhance quality of care,” says Jennifer Colwill, MSN, RN, CCNS, PCCN, Clinical Nurse Specialist – CV Step-down Units. “It’s an important metric for achieving Magnet® status. And for nurses, it enhances professionalism and engagement.”

“I’m so excited Cleveland Clinic supports certification,” says Gronsky, a 22-year nursing veteran. “You have to be at the top of your game to maintain certification. It’s helped me professionally and benefited my patients.”

Nurse Mentors Educate Patients, Peers on Diabetes

Approximately one-third of adult patients admitted to hospitals have diabetes. Many are admitted for other acute conditions. While diabetes may not be a primary diagnosis for admission, relegating the condition to a lesser priority during hospitalization is detrimental to patients. In 2009, clinical nurse specialists at Cleveland Clinic designed and implemented a Diabetes Management Mentor Program to enhance nurses’ knowledge in caring for diabetes patients.

“The Diabetes Management Mentor is an advocate for both the patient and the nurse, empowering both groups with knowledge and fostering a sense of self-confidence in their decision making,” explains Mary Beth Modic, MSN, RN, CDE, Clinical Nurse Specialist – Diabetes. The role of the 35 mentors at Cleveland Clinic’s main campus is to:

  • Identify patient learning needs regarding diabetes
  • Teach diabetes survival skills to patients and their families
  • Advocate for patients when glucose control is suboptimal
  • Identify patients with complex learning needs and refer them for inpatient instruction by the certified diabetes educator
  • Foster diabetes problem-solving skills of peers
  • Facilitate outpatient referrals to Diabetes Self-management Education
  • Direct colleagues to appropriate diabetes resources

Nurses who want to become mentors must successfully complete two diabetes prerequisite courses, then take a mentor preparation course. The interactive course is facilitated by a clinical nurse specialist, a nurse educator and a certified diabetes educator. It covers medication management, insulin delivery devices, glucose monitoring techniques, carbohydrate counting, symptom management and more. Ongoing monthly education also occurs.

“Our mentors have acquired confidence in their knowledge of inpatient diabetes management strategies and frequently serve as catalysts to critical thinking and problem solving in specific clinical situations,” says Modic. One mentor shared the story of a patient who was adamant about stopping his bedtime Lantus® dose. Using knowledge and skills gained in training, the mentor expressed her concerns with his decision and explained the rationale for continuing the medication. The patient changed his order.

“Together, the CNS and the Diabetes Management Mentor are leaving their imprint on the future of nursing practice,” says Modic.

For more information on mentors, read “A Diabetes Management Mentor Program: Outcomes of a Clinical Nurse Specialist Initiative to Empower Staff Nurses.” Mary Beth Modic was one of five authors to publish the article in the September/October 2012 issue of Clinical Nurse Specialist®, the International Journal for Advanced Nursing Practice.