Notable Nursing Update: Spring 2013

Protocols for Catheter Removal Are Empowering Nurses

One of the mandates in the Skilled Nursing Unit at Lakewood Hospital states that patients should not have indwelling urinary catheters (IUCs) unless there is a supporting diagnosis. This rule was extended throughout the hospital into all inpatient medical units just a couple years ago.

Patricia Taseff, RN, Nurse Manager of the Skilled Nursing Unit, discussed the problems associated with catheters and infections with William J. Riebel new Vice President of Medical Operations at Lakewood Hospital, an infectious disease physician, and Lisa Rink, BSN, RN, Nursing Quality Manager at the hospital. The three agreed there should also be established best practices for the removal of the IUC.

“We thought it would be a great project to take to frontline staff and ask what the barriers are to getting Foley catheters removed,” says Rink. Two years ago, the Lakewood Hospital Nursing Shared Governance Council began a project to develop an IUC removal protocol. The group started by examining evidence-based research from The Joint Commission and Surgical Care Improvement Project measures on Foley catheter removal. They discussed who receives IUCs and why, then drafted an IUC removal protocol.

The document was reviewed and edited by several hospital groups, including the Infection Control Committee, Nursing Operations Council, the Chief Nursing Officer and the Medical Executive Committee. “Because this is a nurse-driven protocol, it is very important that the physicians approve it,” says Taseff. “They are not going to be called about all Foley removals, so nurses need to look at the protocol like an algorithm and make decisions on a patient-by-patient basis.”

The IUC removal protocol, which received final approval from the Shared Governance Council in February, includes patient assessment information, indwelling urinary catheter criteria and the standard of care following removal of an IUC. It provides detailed guidance on what Foley catheters nurses can remove using their clinical judgment and which ones they need to collaborate on with physicians.
The protocol was rolled out hospital-wide. Nurses are now educated via the hospital’s nursing newsletter, during mini-huddles and through internal communications from Mary Sauer, MBA, BSN, RN, Lakewood’s Chief Nursing Officer. The protocol is also be posted electronically and sent to all medical staff.

“The protocol gives nurses the ability to use critical thinking and tie in everything they’ve learned in school – along with their experience – to promote the best patient care,” says Rink.

Nurses Go ‘Skin Deep’ To Learn About Pressure Ulcers

Pressure ulcers, which can occur in healthcare settings or at home, affect more than 2.5 million people annually, according to the Centers for Disease Control and Prevention. Identifying, staging and documenting pressure ulcers within critical care settings is essential to providing quality care. In 2010, Skin Care Resource Nurses for the cardiovascular intensive care units (CVICUs) at Cleveland Clinic’s main campus examined the units’ weekly skin care rounding and found that nurses needed more education on pressure ulcers.

“We really wanted to take our preventive skin care measures to the next level,” says Shannon Pengel, MSN, RN, Clinical Nursing Director of The Sydell and Arnold Miller Family Heart and Vascular Institute. “With the help of nursing leaders, clinical nurse specialists and the Shared Governance Council, we decided the NDNQI Pressure Ulcer Training modules would be a great way to do this.”

To encourage nurses to participate in the online training, the unit-based Shared Governance Council launched a contest called “Let’s Get Skin Deep!” The main campus has six CVICUs divided between two floors, employing more than 300 nurses. The floor with the most nurses to complete the training within one month earned a pizza party. To accommodate schedules, the Shared Governance Council held two kick-off events – one during the week and one on a weekend.

During these training events, nurses received breakfast or lunch and entered hourly raffle contests for gift cards. The 85 nurses who attended took a quiz testing their knowledge of stage I, II, III and IV pressure ulcers and were then invited to participate in the online NDNQI Pressure Ulcer Training modules. After completing the training, nurses re-took the pressure ulcer quiz. Nurses who could not attend were able to participate in the training at another time or off site.

At the end of the competition, 73 percent of nurses on one floor and 74 percent on the other floor had taken the pressure ulcer training. “Nurses demonstrated improvement in their ability to identify ulcers and distinguish pressure ulcers from vascular or diabetic ulcers,” says Myra Cook, MSN, RN, ACNS-BC, CCRN, Clinical Nurse Specialist with Cleveland Clinic. Quiz scores after the training improved (by an average of?) 15 percent, and 100 percent of the nurses reported improved comfort levels with staging pressure ulcers. The CVICUs continue to measure pressure ulcer rates, staging and documentation.

Equally important is the pride nurses took in developing and overseeing the training and the contest. Let’s Get Skin Deep was one of the first nurse-led initiatives on the CVICU, says Pengel. Since then, the unit-based Shared Governance Council has spearheaded projects on pain management and infection control.

“Nurses are in the trenches. They can best identify their needs and what will help meet those needs,” says Cook. “I have the clinical expertise, management has the authority to execute ideas, but the staff members are in the best position to come up with solutions to problems.”

Express Care for Common Ailments Is Taking Off

Actors on tour with traveling theater productions who have sinus infections. Corporate executives with seasonal allergies. Even medical specialists with flu-like symptoms. These are just some of the people Jeffrey Arnovitz, MSN, CNP, and his colleagues treat at the Independence Family Health Center Express Care facility.

“Express Care gives people same-day access to healthcare in an office setting,” explains Arnovitz, who began working at the Independence Express Care – Cleveland Clinic’s first one – when it opened in 2009. “We see common medical conditions and charge an office co-pay, which is very attractive to people.”

Cleveland Clinic Regional Operations currently manages Express Care facilities at five family health centers and plans to open three more across Northeast Ohio soon. The facilities are open on weekday evenings and Saturday and Sunday from 11 a.m. to 7 p.m. And these hours will soon expand to meet the growing demand. Starting April 1, Express Care locations will be open 1 p.m. to 9 p.m. on weekdays and 8 a.m. to 4 p.m. on weekends.

“Our patients want convenient hours,” says Ruthann Gavrilescu, MEd, BSN, RN, Director of Nursing for Regional Operations. “They don’t want to take a day off of work or leave early for an appointment. Being able to come at night or on weekends is very appealing to patients.”

Numbers back up Gavrilescu’s assertion: Cleveland Clinic’s Express Care facilities had 34,861 patient visits last year, up 22.4 percent from 2011. Each location is staffed with advanced practice nurses, physician assistants, licensed practical nurses and a receptionist. They treat the following:

  • Cold and flu
  • Conjunctivitis
  • Ear and throat infections
  • Minor bumps and cuts
  • Seasonal allergies
  • Skin rashes
  • Simple sprains and strains
  • Sinus infections
  • Urinary tract infections
  • Upper respiratory tract infections

Express Care fills a gap in healthcare, tending to patients who don’t require emergency treatment, can’t get a last-minute appointment with a primary care physician or don’t have one. The facilities also offer follow-up appointments.

Though the ailments are common, occasional cases are far from ordinary. Arnovitz recently saw a geriatric patient with labored breathing. He ordered an X-ray at a nearby facility, which revealed that the patient had a hemopneumothorax. Arnovitz admitted the man to Cleveland Clinic’s Marymount Hospital, where they successfully treated his collapsed lung.