critical care

Critical Care Nursing’s Role in Prevention of Harm: Going Back to the Basics with Evidence Authors: Kathleen M Vollman MSN, RN, FAAN, CCNS, FCCM (USA) Pang Nguk Lan RN, MSc, INCC, CERM (Singapore) Shelley Schmollgruber PhD, RN (South Africa) Disclosures; Kathleen Vollman Speakers Bureau and Consultant for Hill-Rom, Sage Products and Eloquest Healthcare © Kathleen Vollman 2015 Learning Outcomes After completing this e-chapter you will be able to: 1. Explain the Interventional Care Model as a framework in redesigning how we approach nurse sensitive care practices and patient outcomes 2. Describe how Sustaining Nursing Clinical Practice framework helps to ensure reintroduction and valuing of evidence basic nursing care in conjunction with the right resources and systems to sustain practice. Chapter 1 2 3. Identify various evidence-based strategies to reduce pressure, shear, friction and moisture injuries. 4. Describe the effect of healthcare-associated infections on mortality, morbidity, and cost of health care 5. Define key care practices based on the evidence that can reduce bacterial load and/or prevent the development of health care acquired infections. 6. Describe ICU acquired weakness and delirium and the impact on short and long term outcomes for critically ill patients 7. Discuss early key in bed and out of bed mobility research findings, their application to practice and the patient focused outcome. 8. A step by step approach to help move evidence-based fundamental care practices into acute and intensive care environments. Chapter Overview In today’s critical care environment, we face a difficult but essential task: to provide comprehensive, compassionate, complex, technological care without causing harm to our patients. To foster a safe patient environment it is our task to examine care practices and processes to identify and attenuate potential for error. This chapter presents the challenges with our current practice of basic nursing care and describes an Interventional Patient Hygiene Care Model for use by nurses in redesigning how we approach nurse sensitive care practices in the future to impact patient outcomes. A change framework is critical to ensure reintroduction and valuing of evidence basic nursing care in conjunction with the right resources and systems to sustain practice. Area’s where critical care nurses can significantly reduce harm include 3 preventing; skin injury, health care acquired infections, deconditioning and cognitive decline. While the list in not all inclusive, knowledge of assessment and evidence based nursing care practices will help the nurse significantly impact both short term and long term outcomes for critically ill patients. Forces Driving Nursing Practice Change A significant force driving change is the evidence based practice movement. Evidence based practice (EBP) is the conscientious explicit and judicious integration of the best available evidence from systematic research.1 The challenge nursing faces in our current culture is often the misrepresentation of evidence-based practice. EBP is often considered only to be practices derived and validated with RCTs. This limited interpretation may lead to our failure to consider evidence that is better than tradition based care. Strong forces of change include those that are driven by organizational and regulatory bodies. In the US the Institute of Medicine (IOM), the Joint Commission, the Agency for Health Care Regulatory & Quality issues (AHRQ), National Quality Forum, the Institute for Health Care Improvement (IHI) have aligned their visions to make health care environments safer and improve the quality of patients’ lives.2-5 The American Hospital Association (AHA)/Health Research & Educational Trust (HRET) Hospital Engagement Network (HEN), comprised of 31 participating states and U.S. Territories and over 1,500 hospitals. As part of the Partnership for Patients Campaign to reduce patient harm by 40 percent and readmissions by 20 percent, the AHA/HRET HEN have resulted in over 69,000 patients who had harm prevented and an estimated cost savings of over $200 million in 2012 and 2013 combined.6 Similar quality and financial forces exist and spread to other part of the world, the Singapore Healthcare Improvement Network (SHINe) is one of the Institute of Healthcare Improvement’s (IHI) Quality and Innovation Centers (QIC). IHI described a QIC as “a leading resource and driving force for system-wide, transformative health care improvement in a system or region committed to better health, better care and lower costs.7 SHINe is an umbrella group 4 composed of member healthcare organizations which are collectively committed to better health, better care and lower cost care to patients. The Network aims to accelerate the pace and scale of improvement, leading to system-wide, transformative healthcare in Singapore.8 The Centers for Medicare and Medicaid’s and third party payers are changing reimbursement structures and limiting or eliminating reimbursement for preventable errors. In the US, the economic ramifications of these changes have helped to focus the momentum on safety and avoiding preventable hospital acquired conditions.9 With patient safety serving as the overriding goal, there is a positive movement within the profession of nursing to “get back to the basics” or “fundamentals of care” to improve care and prevent nurse associated errors/harm such as: health care acquired infections, development of pressure ulcers and failure to rescue.10 The majority of these nursing care practices fall into the category of hygiene and mobility interventions. So if nursing’s fundamentals of practice are not routinely being employed as suggested by data on nurse sensitive outcomes, what are the reasons and what can we do about them? One theory suggests that the basics of care may be absent or devalued because of limited structures that assure reinforcement of the importance of the basics, reward/recognition for doing them, or failure to hold nurses accountable.11 While untested, the theory may be used by nurses to examine the value of these care practices within their work culture. This may help identify the need for a change in culture that stresses the importance of basic nursing care functions as supported by the best evidence.12 For example, many nurses are able to identify or know when they make a medication error or failed to follow a physician’s order. However, prior to the current world wide patient safety movement, most frontline critical care nurses were unaware of data related to nurse sensitive outcomes such as ventilator associated pneumonia, blood stream infection; pressure ulcer incident and urinary tract infection. These indicators are all considered nurse sensitive outcomes for the quality of nursing 5 care delivered.13 As noted by BF Skinner “behavior that is reinforced continues behavior that is not reinforced stops”.14 In essence, care practices, and their value, may have been “conditioned” out of the nurse. The disease focused model of diagnosis and treatment has been the dominant care delivery model within most of our acute care environments. Unfortunately, prevention of complications has been less so. It is time for our profession and each individual nurse to reclaim the fundamentals of nursing that are essential to positive patient outcomes and use evidence based practice to drive the transformation. Interventional Patient Hygiene: Building a Usable Model This transformational journey is similar to launching a campaign and therefore may benefit from a recognizable name and model to help ensure the transformation. Use of a model may help clarify and provide a means to articulate nursing’s unique contributions to healthcare. Two categories, evidence-based interventional hygiene and mobility strategies, if placed within the context of a comprehensive program for reducing error, may help prioritize a list of care activities for critical care nurses. Positive outcomes may follow. Webster’s dictionary defines hygiene as the science of prevention of illness and the maintenance of health.15 The goal of basic nursing care is to proactively intervene with nursing interventions that focus on using evidence-based hygiene and mobility strategies to reduce health care acquired infections and skin injuries. These hospital-associated conditions are linked to increases in patient morbidity and mortality as well as significant cost burden to our health care systems. The term “Interventional Patient Hygiene” (IPH) was created as a model for a systematic approach using evidence based nursing care interventions to prevent health care acquired conditions.16 The components of the model include oral cleansing, patient mobility, maintenance of a central line, urinary catheter care, bathing to reduce bacterial load and skin prevention strategies.12 Figure 1. McGuckin et al expanded the IPH model to incorporate hand hygiene and skin antisepsis.17