Notable Nursing: Update, July 2013

Families Play Primary Role in NICU RoundingFamilies Play Primary Role in NICU Rounding

The Neonatal Intensive Care Unit (NICU) at Fairview Hospital holds family-centered daily rounds. Parents, or the infant’s support person, participate in rounding between 9 a.m. and 11 a.m. with the primary physician, nurse, nurse practitioner and clinicians from other disciplines,  including respiratory, pharmacy and nutrition.

“The family is an integral part of our care with patients,” says Charlene Nauman, BSN, RN, a NICU direct-care nurse. “Not only do we treat the little patients—the preemies or newborns—but we also have to treat the family because they come as a unit.”

The NICU adopted family-based rounds a couple years ago, after nurses raised concerns about rounding practices during staff meetings. Sometimes physicians rounded without them or several rounds occurred, with nurse practitioners, specialty clinicians and physicians arriving at different times. An interdisciplinary team, led by NICU Medical Director Jalal Abu-Shaweesh, MD, studied the unit’s rounding practices and developed the new format.

Family-centered rounds emphasize relationship-based care, a primary tenet of Cleveland Clinic Zielony Nursing Institute’s professional practice model. The rounds facilitate team communication, encourage family bonding at the bedside, complement the nurse’s role as a patient advocate and prepare the family for discharge. On admission, nurses educate parents on the process of daily rounds and a written explanation is included in their welcome packet.

During daily family-based rounds at the bedside, participants:

  • Assess the patient’s needs and discuss concerns
  • Determine the plan of care for the next 24 hours
  • Answer questions and explain terminology

Family members are invited to be active participants in the rounding because they offer invaluable insights into how their infants react to feedings, treatment and care. “The most important thing we can do with parents is make them feel they have choices and are part of the care,” says Denise Speer, BSN, RN, clinical nurse manager of the NICU. “When parents come to us, they feel at a loss. All their control has been taken away. By having them participate in decisions, it gives them some control back and helps them feel better about their stay here.”
The new rounding method has increased family satisfaction. In 2011, Fairview Hospital NICU’s Press Ganey score for overall satisfaction was 76 percent. That number increased to 82 percent in 2012.

Employee engagement has also increased. In a 2011 survey, 58.4 percent of NICU nurses indicated their opinions count. Last year, that number escalated to 77.4 percent. In addition, more than 90 percent of nurses said they know what’s expected of them and have an opportunity to learn and grow.

“Every day we learn more about how we do rounds,” says Speer. “And every day our goal is to continue to make it better.”

Addressing Patients with Diabetes Through Hypoglycemia ProjectAddressing Patients with Diabetes Through Hypoglycemia Project

Patients are admitted to the H80 medical unit at Cleveland Clinic’s main campus for a variety of reasons, ranging from foot ulcers to pneumonia. Some also have diabetes as an underlying condition. “Because patients have another primary diagnosis, diabetes management tends to fall down on the list of priorities,” says Mary Beth Modic, MSN, RN, CDE, Clinical Nurse Specialist – Diabetes. Last year, the unit participated in a hypoglycemia project to change that.

Cleveland Clinic’s Quality & Patient Safety Institute sponsored the interdisciplinary project, led by endocrinologist Christian Nasr, MD, and including a team of staff nurses, H80’s nurse manager, pharmacists and dietitians. The goal was to eliminate blood glucoses (BG) < 40mg/dL.

In October, clinical nurse specialists spent one week on the medical unit observing nurses prepare insulin, provide hand off reports and discuss diabetic patients with staff. Modic says they found several opportunities for growth, including the following:

  • Hand-off communication
  • Coordination of blood sugar tracking, meal delivery and insulin administration
  • Completion of one-hour checks after treatment for low BGs, per the hypoglycemia protocol

The interdisciplinary group analyzed the data and shortcomings, then devised a series of practice changes to trial from Oct. 29 through Dec. 31, 2012. These changes included:

  • Revising the insulin order sets. They were streamlined, and recommendations for ordering insulin were incorporated.
  • Educating RNs, PCNAs, residents and pharmacists on the hypoglycemia protocol. Nurses and PCNAs utilized an online training module including a test at the end. PCNAs also participated in mini in-services on meal consumption and rounded with the dietitians.
  • Changing workflow. The pantry announced to the health unit coordinator when diabetic trays were being passed out to allow more timely insulin administration. PCNAs altered their point-of-care testing: Rather than checking BGs on every patient then reporting the results, the PCNA now tested one patient and immediately shared results with the nurse, who then entered the results in the electronic medical record.
  • Improving hand-off communication. Nurses shared if the patient had type 1 or type 2 diabetes, had previous hypoglycemic events, how low the BG was and how the patient responded to treatment.

After the trial, the group evaluated the outcomes and studied every hypoglycemic event. “We didn’t see the decline in hypoglycemia we had hoped for,” admits Modic. She says a handful of factors created challenges. For instance, Cleveland Clinic began using a new food service company during the trial. But there were upsides. “Adherence to the protocol increased, and nurses were more aware when meals were delivered,” says Modic.

Cleveland Clinic is creating a strategy for hospital-wide implementation. Says Modic, “The program has increased interest in diabetes and helped our staff become more conversant in the nuances associated with the condition."

Cleveland Clinic Nurse Helps Set Best PracticesCleveland Clinic Nurse Helps Set Best Practices

Kathy Hill, MSN, RN, CCNS, has been a nurse for 36 years and her enthusiasm and desire to advance the profession are as strong as ever. That’s one of the reasons this clinical nurse specialist, who supports the surgical intensive care unit on Cleveland Clinic’s main campus, remains active in the American Association of Critical-Care Nurses (AACN).

“It’s very invigorating to talk to other critical care nurses who share the same passion for improving quality of care at the bedside,” says Hill. Two years ago, she was invited to join AACN’s Evidence-Based Practice Workgroup. The group of 10 advanced practice nurses, bedside nurses and academics develop practice guidelines that are used around the world by critical care nurses.

The workgroup has written and revised several guidelines—called Practice Alerts—during Hill’s tenure, including one that is soon-to-be-released on bathing patients. “That may not sound very exciting, but it is an activity solely owned by nursing,” says Hill. “The Practice Alert will influence skin care and transmission of infection.”

In addition, the workgroup is developing best practices related to alarm fatigue, pressure ulcer prevention, pain assessment, oxygen saturation monitoring and inter-professional collaboration. “Our Practice Alerts are eventually incorporated into the policies and protocols of most healthcare organizations in the country,” says Hill.

That’s certainly true at Cleveland Clinic, where the Adult Intensive Care Unit Practice Council reviews AACN guidelines when setting policies, procedures and protocols. The council is comprised of staff nurses, nurse managers, clinical nurse specialists and clinical instructors from all adult ICUs. “When the AACN comes out with a new practice, we look at our current procedures to make sure we are consistent with recommendations,” says Hill.

For example, the new Practice Alert on delirium management advocates using the Confusion Assessment Method ICU tool (CAM-ICU). “Some of our ICUs were slower to adopt a delirium assessment tool,” says Hill. “So when the AACN endorsed the CAM-ICU that encouraged us to move forward and use it.”

Hill says being a member of the Evidence-Based Practice Workshop helps Cleveland Clinic remain on the forefront of nursing best practices. She shares the latest information with the health system, which promotes involvement in professional organizations. It’s also personally rewarding for Hill. “It’s gratifying to know that I am influencing the practice of bedside nurses everywhere,” she says.