A Clinical Nurse Specialist-Led Sepsis Team: An Innovative Approach to Improving Patient Outcomes

Valerie Smeltzer, BS, RN, CCRN-CSC, York College of Pennsylvania, Craley

Purpose/Objectives: Improve outcomes in septic patients by developing a dedicated team of expert nurses armed with real-time data to guide clinical decision-making.

Significance: The rate of severe sepsis hospitalizations has doubled in the last decade with an estimated 750 000 patients being affected each year. Efforts to reduce high mortality rates associated with sepsis led to the Surviving Sepsis Campaign of 2004. Its recommendations include providing patients with early goal-directed therapy, a protocol for septic shock patients that emphasizes optimizing tissue perfusion.

Design/Background Rationale: A higher than expected mortality rate for sepsis patients was identified, and an action plan was devised by an interprofessional team consisting of physicians, nurses, respiratory therapists, pharmacists, and information technology specialists. A clinical nurse specialist (CNS) led the "sepsis team."

Description of Methods: Experienced ICU nurses were recruited for the sepsis team, and standing orders, which would ensure timely initiation of early goal-directed therapy, were developed for them to initiate. To more promptly identify septic patients, a 24-hour sepsis alert system was developed. Using laboratory data and vital signs entered into the electronic medical record, alerts were sent out via e-mail and to a dedicated pager when patients met any 2 criteria for systemic inflammatory response syndrome along with 1 criterion for organ failure. The sepsis team nurse can then intervene to ensure the patient is receiving appropriate treatment. The nurse also assists with determining the appropriate level of care for the patient, placement of invasive lines, and initiation of pressors.

Findings/Outcomes: Prompt implementation of the sepsis bundle has improved outcomes with a reduction in septic shock mortality rate from 38% to 11%.

Conclusions: The CNS was able to affect change within all 3 spheres of influence in the development of the sepsis team. Better patient outcomes (client sphere), improved staff knowledge of sepsis and appropriate interventions (staff sphere), and improved collaboration with physicians (organization/system sphere) have all been realized through the efforts of the CNS.

Implications: This collaborative approach, facilitated by a CNS, resulted in improved compliance with Surviving Sepsis Campaign recommendations and reduced mortality from septic shock.

A Program Evaluation of an Educational Intervention to Improve Nurses' Knowledge of Heart Failure

Cristin Phillips, University of Wisconsin-Milwaukee College of Nursing

Purpose/Objectives: The purpose of this research was to determine if an educational intervention improves nurses' knowledge of heart failure and to evaluate the relationship between nurses' self-rated knowledge to perform heart failure education and their tested knowledge of heart failure.

Significance: Heart failure remains among the top 5 causes of mortality in the United States despite major advances in pharmacology and technology. The number of people diagnosed and hospitalized with heart failure rises yearly. Effective patient management of heart failure is needed to optimize patient outcomes. Nurses play a key role in patient education and need to be sufficiently prepared to educate people with heart failure to realize further improvement in patient outcomes.

Design/Background Rationale: Kurt Lewin's Change Theory emphasizes that change occurs through unfreezing current perceptions, instituting change, and refreezing.

Sample/Population: A convenience sample of registered and graduate nurses from a 23-bed inpatient cardiac unit participated in this program evaluation.

Description of Methods: Following institutional review board approval, participants were asked to rate their knowledge of heart failure on a 0- to 10-point scale. Albert's 20-item true/false test of heart failure management principles was used to measure actual knowledge. Self-rated and actual knowledge was measured before and after an educational session provided by the clinical nurse specialist student.

Findings/Outcomes: The pretest was completed by 29 participants. There were no statistically significant differences in the actual knowledge scores before and after tests (t₅₇ = -1.67, P = .109), although there was a slight increase in the average scores between pretest and posttest: 82% and 85% respectively. Self-rated knowledge confidence had a very low correlation with test score (Pearson r = 0.136, n = 57).

Conclusions: Results support previous research and provide further evidence that most nurses are not adequately prepared to complete heart failure teaching.

Implications: Clinical nurse specialists are challenged to unfreeze self-ratings of knowledge by using interventions such as active learning and personal feedback, thus enabling nurses to recognize the gap between self-rated and actual knowledge. Once aware of the gap, theory suggests that nurses' knowledge can be changed.

An Evidence-Based Nursing Intervention to Maintain Muscle Strength for Balance in the Hospitalized Older Adults

Stephanie Heckman, RN, CMSRN, Indiana University School of Nursing, Indianapolis

Purpose/Objectives: This presentation will discuss an evidence-based nursing intervention to maintain muscle strength and promote balance in hospitalized older adults.

Significance: Research identifies muscle disuse as a precursor to functional decline among hospitalized older adults. An estimated 23% to 33% of older adults hospitalized for acute illness experience low mobility, which includes being confined to the bed or chair. Mobility-related deficits have been shown to have devastating functional effects, including loss of independence, increased rate of falls, and higher incidence of pressure ulcers. Even though research findings demonstrate clearly that maintaining mobility during hospitalization will preserve functioning, there are few nursing interventions for older adults designed to prevent muscle disuse.

Design/Background Rationale: This project used literature review to create an evidence-based mobility intervention for promoting muscle use and balance ability among hospitalized older adults.

Description of Methods: The literature was reviewed to identify the physiological mechanisms contributing of muscle disuse and functional decline. An intervention was designed to target the etiology muscle disuse, focusing on the cores muscles needed for balance and walking. This etiology was selected because core muscles of balance are most sensitive decline due to disuse, and among older adults, disuse results in rapid decline. The innovative intervention consisted of balance training for patients for whom mobility is limited because of medical therapies, such as monitors or devices. Patients are assisted to stand at the bedside 3 times per day. The length of time and frequency of the balance training are gradually increased until the patient is able to bear weight and stand independently.

Findings/Outcomes: In clinical practice, patients found the balance exercises to be acceptable and were appreciative of nurses' efforts to increase physical activity to overcome the limitations of hospitalization.

Conclusions: Balance training was found to be a straightforward intervention that can be implemented easily in the hospitalized older adult.

Implications: Routine nursing care should incorporate exercises to maintain and improve balance in older adults during episodes of acute illness.

An Evidenced-Based Intervention for Promoting Sleep in Infants Experiencing Neonatal Abstinence Syndrome (NAS) Due to Maternal Methadone Use

Marianne Hiles, BSN, RNC-LRN, Indiana University School of Nursing, Indianapolis

Purpose/Objectives: The purpose of this project was to design an evidenced-based intervention for infants experiencing physical discomfort caused by central and autonomic nervous system changes resulting from neonatal abstinence syndrome (NAS), manifested as problems achieving continuous, quiet sleep.

Significance: While methadone use during pregnancy for women with opiate addictions prevents many negative consequences for mother and infant, the infant becomes opioid dependent. Once born, many infants experience a cascade of symptoms known as NAS. These symptoms cause discomfort due to the neonate's inability to modulate pain, resulting in an alteration in state regulation. The resulting discomfort produces a decrease in periods of continuous, quiet sleep which is necessary for brain plasticity, organization, and maturation.

Design/Background Rationale: There are many well-designed, evidence-based interventions for infants born prematurely centered around developmentally appropriate strategies to promote an optimum healing environment for the neonate. The literature regarding evidenced-based nursing interventions for the population of infants experiencing NAS is limited. The design of this intervention was based on the neurobehavioral perspective of Brazelton, who theorizes that the plasticity of the infant's brain and the disorganized central nervous system can be positively affected by a nurturing environment.

Description of Methods: Using literature as data, a "skin-to-skin" intervention was designed to promote infant comfort and sleep. The infant, dressed only in a diaper, was placed skin to skin vertically on the mother's chest, with his face turned to the side for adequate ventilation. The mother was positioned for comfort in a rocking chair, and both were covered with a blanket for the period of 1 hour following the infant's feeding. Afterward, the infant was transferred to the crib.

Findings/Outcomes: In clinical practice, skin-to-skin care is demonstrating effectiveness in decreasing infant pain scores while improving continuous quiet sleep.

Conclusions: Based on the evidence available and clinical practice, this intervention appears to be effective intervention for infants experiencing NAS.

Implications: The role of the clinical nurse specialist in designing innovative, evidenced-based interventions in the population of infant's experiencing NAS is necessary for decreasing discomfort, increasing state stabilization, and periods of quiet sleep. These interventions benefit not only the infant, but also the maternal-infant dyad.

Competency Assessment: Use of a Clinical Safety Investigation Room

Elizabeth Moran, RN, University of Illinois at Chicago

Purpose/Objectives: The purpose of this article is to describe how the use of a specific simulation activity used the principles of the Adult Learning Theory to validate competency.

Significance: The development of innovative methods to evaluate competency assessment in staff nurses remains a challenge for clinical nurse specialists.

Design/Background Rationale: Use of a clinical safety investigation (CSI) room was used to assess competency during an annual competency skills day at a large urban university medical center. The Adult Learning Theory, simulation, and debriefing were used to develop this tool for competency assessment.

Description of Methods: A clinical scenario was created to facilitate the development of a simulated patient experience. Through the simulation, clinicians had to critically think about the safety concerns presented. Finally, including oral debriefing after clinicians participated in the simulation allowed for a true reflection of their understanding and validation of knowledge related to the topics. All clinical staff were required to participate. Job specific competencies were identified as the clinician's ability to recognize a blood transfusion reaction and properly identify a patient with contact precautions for Clostridium difficile.

Findings/Outcomes: Evaluations from 135 staff revealed that 99% of them felt the CSI room challenged their clinical knowledge, and 98% preferred the CSI room as a method to validate competency. Approximately 800 clinical staff completed competency assessment using the CSI room.

Conclusions: Based on the findings, the use of a CSI room incorporated the principles of the Adult Learning Theory to produce an innovative method for validating competency.

Implications: The use of simulation in the form of a CSI room can be used to validate competencies for a number of job-specific competencies. Future use of this type of simulation should involve a greater number of clinicians evaluating the simulation and greater control of one-on-one debriefing.

Development of an Algorithm for the Management of Postoperative Nausea and Vomiting in the Day Surgical Setting

Lynn Gettrust, MSN, RN, ACNS-BC, Alverno College, Milwaukee, Wisconsin

Purpose/Objectives: To develop a consistent approach to the management of postoperative nausea and vomiting (PONV) in patients undergoing general anesthesia in the day surgery setting.

Significance: Postoperative nausea and vomiting is the most frequent side effect of general anesthesia, producing a range of physical symptoms from mild to severe. The potential implications of PONV include medical complications, increased nursing care needs, delayed discharge, and overnight hospitalization. Postoperative nausea and vomiting can impact patient satisfaction with their overall surgical experience.

Design/Background Rationale: This process improvement project was designed to develop and evaluate resources for nurses caring for patients identified as "at risk" for PONV. For this project, a risk identification instrument was used by nurses preoperatively to assess patient risk for developing PONV. In addition, 2 evidence-based algorithms were used to inform nursing practice. The preoperative algorithm focused on prophylactic treatment of patients identified at risk for PONV. The postoperative algorithm served as a guide for nurses caring for patients experiencing nausea and vomiting following surgery.

Description of Methods: The plan-do-study-act process was used for this project. During the plan phase, decisions were made about which tools to use: a PONV risk identification instrument and 2 algorithms for the management of PONV. In the do phase, nurses from day surgery and the postanesthesia care unit were trained in the use of the risk identification instrument and algorithms. Nurses used these tools for 2 weeks. In the study phase, an analysis was made of the nurse's satisfaction with use of the risk identification instrument and algorithms. The final phase is act. Revisions were made to these tools based upon analysis of the results of nurses' satisfaction in using them in practice. Further decisions regarding implementation of these guidelines will be made at the organizational level of this community hospital.

Findings/Outcomes: Twenty-four nurses completed the PONV evaluation form. The risk identification instrument and algorithms were evaluated for their ease of use and applicability to practice. For the risk identification instrument, the nurses were satisfied with the ease of use and applicability to practice. For the preoperative algorithm, the nurses were satisfied with the ease of use and very satisfied with the applicability to practice. For the postoperative algorithm, the nurses were very satisfied with the ease of use and applicability to practice.

Conclusions: Overall, nurses were satisfied with the ease of use and applicability to practice of the risk identification instrument and preoperative and postoperative algorithms.

Implications: Use the risk identification instrument and PONV algorithms with adult day surgery patients having general anesthesia to measure patient outcomes.

Implementing a Skin Care Assessment Nursing (SCAN) Team to Reduce the Prevalence of Pressure Ulcer in Acute Care Setting

Nkechi Ileka, The Catholic University of America, Frederick, Maryland

Purpose/Objectives: To examine the effectiveness of a SCAN (skin care assessment nursing) team program in pressure ulcer (PU) reduction.

Significance: Pressure ulcer prevention and management remain a burden in the health care system, and an enormous amount of time and energy are spent on planning PU prevention strategies. Pressure ulcers cause unnecessary pain and suffering for the patients and are associated with increased morbidity and mortality. Pressure ulcer treatment is an economic burden, and several studies have shown that the cost to treat PUs is from $2000 to $70 000 per wound. The national cost for the treatment of PU is between $1.3 and $3.5 billion annually. Hospitalizations associated with PU as a primary diagnosis were said to be about 1 death in 25 admissions, and hospital mortality rate has been shown to be higher among those who were hospitalized with PU as a secondary diagnosis. Pressure ulcer prevention is important. The quality of nursing care is crucial in preventing PUs; therefore, it is imperative that the appropriate preventive measures are implemented.

Design/Background Rationale: The organization of interest continues to struggle with a PU prevalence rate of 16.9%.

Description of Methods: This project will look at the effectiveness of a SCAN team program in reducing PUs over a 6-month period. The Iowa Model will be applied to this project. This model serves as a framework to improve patient outcomes.

Findings/Outcomes: This project is in the preliminary phase and has not been implemented.

Conclusions: Pressure ulcers are preventable in many cases. A targeted preventive approach will be less costly than one that is focused on treating already acquired PUs.

Implications: As reported by Centers for Medicare & Medicaid Services in 2007, hospital-acquired PUs are now considered never events, and the proposal to not fully reimburse hospitals for owning PU will affect hospital financial costs. Unless appropriate PU preventative measures and interventions are applied to nursing practice, PU prevention will remain at a high cost in health care.

Midline Catheters: Introduction at Pitt County Memorial Hospital

Denise Harper, MSN, CNS, CRNI, Greenville, North Carolina

Purpose/Objectives: The purpose of this project was to implement midline catheters over a 3-month period and evaluate the implementation.

Significance: Many patients have unnecessary central lines due to exhausted peripheral access. These lines cause an unnecessary risk for infection, increase in patient cost, and decrease in revenue. Central line-associated bloodstream infections are estimated to cost up to $45 000 per infection; with approximately 250 000 occurrences and 30 000 deaths per year.

Design/Background Rationale: To provide the best possible infusion care for patients, the facility needs to offer various options in access devices. Staff needs education on access issues, devices, and their appropriate utilization for maximum patient benefit. Midlines are an extended dwell peripheral intravenous catheter. They can provide access for up to 6 weeks without repeated needle sticks.

Description of Methods: Midline insertion classes were provided multiple times per day, for 4 days. Roving in-services were provided on each floor regarding indications, care, and maintenance. During this time, we searched for opportunities for supervised placements. Information tracked included number of midlines attempted, estimated costs, and potential to decrease central line use.

Findings/Outcomes: Between April 23, 2010, and July 22, 2010, 50 individuals were trained to insert midlines. Sixteen individuals attempted placements, with 8 individuals being successful. Fifty midline attempts were made, 27 of them by 1 individual. Nineteen placements were successful for an overall success rate of 38%; 12 of the 19 were by 1 individual with a success rate of 44%. Analyses of insertion costs were estimated and revealed: peripheral intravenous, $23; midline, $113; peripherally inserted central catheter, $310 (does not include procedure charge).

Conclusions: The more attempts made, the more successful/proficient one becomes. Many potential opportunities for midlines were lost. Barriers include role conflict, limitations educating staff, patients with multiple comorbid factors, and lack of support. Lessons learned include sticking to your original plan, keeping it small, and being prepared for nonsupportive people.

Implications: Improved patient and nurse satisfaction, improved patient outcomes, cost reduction, and cost savings are possible, but more research is needed.

Nurse Established and Managed Electronic Communication in Pediatric Home Health

Tina Haney, MSN, RN, CNS, Old Dominion University, Norfolk, Virginia

Purpose/Objectives: The purpose of this pilot study is to explore self-reported perceptions of well-being and satisfaction of parents of medically fragile and technologically dependent children cared for at home prior to and following the implementation of a nurse managed electronic communication in the form of e-mail and texts.

Significance: This project may potentially highlight an effective strategy for communicating with parents of medically fragile and technologically dependent children cared for at home.

Design/Background Rationale: A growing number of children's survival are dependent on community-based advanced medical technologies and expert nursing care once provided in the hospital. Current numbers estimate that 500 000 children are cared for at home. Parenting a medically fragile and technologically dependent child at home causes unique emotional and physical demands. Parents report feelings of social isolation, loss of control, and blurred boundaries between themselves and home care nurses. Few studies have addressed solutions or specific interventions that nurses can undertake to promote family well-being. A 1-group pretest and posttest design was utilized.

Description of Methods: The setting is a pediatric home health care agency. A convenience sample was recruited via invitational letters. Inclusion criteria included (a) parents or legal guardians of children cared for by the pediatric home health care agency, (b) reported ability to read and write English, (c) access to Internet or smart phone technology, and (d) residents of specific region. Self-reported perceptions of well-being and satisfaction were measured before and after implementation. Parent well-being and satisfaction are measured by the PedsQL Healthcare Satisfaction Generic Module and the PedsQL Family Impact Module. A group of 20 parents participated in a 3-month nurse established and managed electronic communication.

Findings/Outcomes: The pilot study is ongoing. Preintervention data have been collected and recorded. Preimplementation and postimplementation questionnaire subset scores will be analyzed with the paired t test.

Conclusions: A conclusion has not been reached as the intervention has not been concluded, and data analysis performed.

Implications: The project aims to improve the parent's self-reported well-being and satisfaction, thereby potentially increasing the family's quality of life.

Solutions to Fragmented Transitional Care in the Geriatric Population

Florence Mandebvu, BS, RN, SUNY Upstate Medical University, College of Nursing, Syracuse, New York

Purpose/Objectives: To provide an evidence-based intervention to decrease geriatric hospital readmissions by implementing a postdischarge telephone follow-up to manage transitional care needs.

Significance: During transition from acute care to home or other non-acute care settings, geriatric patients are vulnerable to fragmented care, resulting in adverse events and readmissions. The number of geriatric patients continues to rise as baby boomers age. In 2003, 13% of the total population of hospitalized patients required recurrent hospitalization, using 60% of resources. Many are geriatric patients.

Design/Background Rationale: According to experts, the elderly often receive fragmented care when transitioning from the hospital to home or other settings. This affects quality of care for patients and sometimes results in readmissions, which is a concern financially for hospitals. At a major university hospital, the clinical nurse specialist (CNS) student found no discharge specific for the geriatric population. This population has unique needs postdischarge compared with the adult patient. The CNS student coled a group whose charge was to improve geriatric discharge planning.

Description of Methods: A literature review (Cochrane, CINAHL, MEDLINE, National Guideline Clearing House, Care Transitions Web site, Robert Wood Johnson Foundation, and the Geriatric Association Web site) was performed. More data were gathered from the University of Colorado, New York University, and the Hartford Institute. Next the CNS student coled a multidisciplinary group to resolve the issues using gap analysis. It was decided that the Acute Care of the Elderly team would review all discharged patients. If it was determined that the patient was at risk for readmission, he/she would receive a telephone call asking specific questions. If a problem was uncovered, then an intervention would occur, such as having his/her contact their health care provider.

Findings/Outcomes: It is expected that the readmission rates for the elderly will decrease. Data will be complete before the conference.

Conclusions: Follow-up care after hospital discharge is needed for the geriatric population. This telephone intervention is one way to provide follow-up.

Implications: The CNS is able to develop and implement needed strategies to improve transitioning from the hospital to home settings for the elderly. This important topic needs more research.

Streamlining STAT Medication Management in the Inpatient Setting

Anushree Ahluwalia, The Johns Hopkins University School of Nursing, Baltimore, Maryland

Purpose/Objectives: To improve STAT medication management in the inpatient setting.

Significance: Inefficient STAT medication management jeopardizes the effectiveness of pharmacotherapy in treatment regimens and thus reduces the quality of care in the inpatient setting. Currently, there are no nationally accepted guidelines for STAT medication management.

Design/Background Rationale: STAT medications are rarely fulfilled within the 30-minute period delineated in the institution-specific policy in the department of medicine (DOM) at a large, urban, academic medical center. The departmental patient safety officer, a clinical nurse specialist, was consulted to examine and analyze the existing medication-use cycle. Her graduate student, a clinical nurse specialist student, assisted with data analysis and summarized the findings for system-wide interventions.

Description of Methods: Recognizing the interdisciplinary nature of medication management, the clinical nurse specialist collaborated with pharmacists and the pharmacy operations manager to identify the gaps in the medication-use cycle. The team reviewed STAT medication orders on a unit-by-unit basis, compared these orders with the unit-based Pyxis medication inventories, and identified all missing STAT medications per unit.

Findings/Outcomes: STAT medication availability was determined to initiate unit-based Pyxis inventory revisions for the DOM. This project was expanded to a multidepartmental initiative as many medications were deemed essential on non-DOM units by the interdisciplinary team.

Conclusions: Interdisciplinary collaboration led to system restructure and streamlined the medication-use cycle in the inpatient setting.

Implications: (1) A clinical nurse specialist is in a pivotal position to impact system-wide changes through interdisciplinary collaboration. (2) STAT medication management may be streamlined at other hospitals based on the findings of this project. (3) Nationally standardized STAT medication management guidelines may emerge as a result of similar initiatives.

The Effect of the Implementation of the Treatment Guidelines for Atrial Fibrillation on the Incidence of Stroke

Joeresty Abelida, BSN, RN, University of the Incarnate Word, San Antonio, Texas

Purpose/Objectives: This study assessed national guideline compliance of oral anticoagulant (OAC) use in atrial fibrillation (AF) patients compared with the incidence of stroke in patients who did and did not receive OAC. Research Questions: (1) Are physicians following the 2006 guidelines for OAC use in AF patients? (2) Is there a difference in stroke incidence between patients who received OAC therapy and those who did not?

Significance: Atrial fibrillation is an independent stroke risk factor with 60 000 new cases annually. In 2006, AHA/ACC/ESC recommended antithrombotic therapy for AF patients except when contraindicated. Patients with 1 stroke risk factor should be anticoagulated with vitamin K antagonist. Noncompliant or low-risk patients may receive aspirin as antiplatelet therapy. Post published guidelines, few US studies document the rate of OAC use among AF patients and its impact on stroke.

Design/Background Rationale/Description of Methods: A hospital's database identified 201 AF patients admitted with the International Classification of Disease, Ninth Revision (ICD-9) code 427.31 from January to December 2007. Using systematic sampling, data on 55 AF patients were collected, for OAC usage and stroke readmissions from January 2007 through December2009, using retrospective medical record review. Data were analyzed using frequency distributions and [chi]² test.

Findings/Outcomes: Participants were 63% Hispanic (35), 67% female (37), and aged 65 to 90, with 53% (29) diagnosed with new-onset AF. High compliance to the guideline was noted with 97% (53) discharged on OAC or antiplatelet therapy. Four patients (7.2%), 3 on OAC and 1 on antiplatelet therapy, compared with 7.8% nationally were readmitted for a stroke diagnosis.

Conclusions: With 97% of all patients placed on anticoagulant therapy, national guidelines compliance for OAC use for stroke prevention is being followed. The size of the group without OAC was too small to measure any statistically significant variations. Larger samples are needed to truly determine the value of OAC in stroke prevention.

Implications: Even with good medical compliance to OAC guidelines, greater than 7% of patients with AF continue to develop a stroke. Patient compliance with OAC therapy may need to be measured by INR to truly assess the value of OAC in stroke prevention.

The Evidenced-Based Nursing Intervention for Muscle Atrophy Experienced by Patients on Antepartum Bed Rest

Jeannie Amoroso-Knight, RNC, Indiana University School of Nursing, Indianapolis

Purpose/Objectives: An evidence-based intervention was developed to lessen muscle atrophy associated with antepartum bed rest.

Significance: The concern over the low birth weight, preterm births, and infant mortality led to bed rest for 1 million American women annually. Bed rest, sometimes lasting for months, is prescribed by 89% to 92% of obstetricians. Within 6 hours of bed rest, the musculoskeletal system begins rapid deterioration. An absolute loss of muscle mass and protein breakdown peak at 3 to 7 days, with the most profound areas of atrophy being the postural muscles in the legs and back.

Design/Background Rationale: Muscle atrophy occurs when protein breakdown exceeds protein synthesis. Negative nitrogen balance is an early marker for the dramatic muscle atrophy seen with bed rest. Muscle protein synthesis increases in response to oral or intravenous feeding due largely to stimulation by amino acids. Prenatal patients on bed rest often lose weight and have leg muscle atrophy. A body of literature concerning body builders exists supporting diet supplementation with amino acids with exercise. While essential amino acids alone stimulate muscle anabolism, branched-chain amino acids, essential amino acids, and carbohydrates taken before exercise achieve maximal anabolic response. With increased oxygenated blood flow with exercise, branched-chain amino acids, essential amino acids, and carbohydrates are expedited into cells, increasing insulin production, increasing protein synthesis, and decreasing protein degradation.

Description of Methods: Prenatal patients (without preeclampsia or hypertension) with ordered bed rest drank a protein supplement prior to physical therapy exercises once a day for 1 month.

Findings/Outcomes: The prenatal patients who drank the supplement before exercising maintained or increased their weight and increased their thigh/calf circumferences.

Conclusions: Protein supplementation before resistive exercises may reduce the atrophy of ordered bed rest, increasing strength needed for daily activities and child care. Efficacy studies are needed to support the intervention.

Implications: The role of the CNS in designing innovative, evidence-based interventions for antepartum bed rest patients is necessary for increasing muscle strength, decreasing muscle atrophy, and rapid recovery of the mother once bed rest is discontinued. These interventions benefit not only the mother, but also the entire family unit.

Therapeutic Hypothermia to Provide Neurologic Protection in Unresponsive Cardiac Arrest Patients

Susan Taber, RN, Upstate Medical University College of Nursing, Syracuse, New York

Purpose/Objectives: The purpose was to initiate a therapeutic hypothermia (TH) protocol in post-cardiac arrest patients to limit neurological dysfunction in patients.

Significance: Each year in the United States, approximately 1 million people experience cardiac arrest. The in-hospital cardiac arrest survival to discharge rate is 3% to 27%. However, there is a 10% to 70% level of neurological damage in patients who survive, and 40% will die of neurological compromise.

Design/Background Rationale: Hypothermia therapy is effective in improving neurological outcomes in post-cardiac arrest patients. In 2002, 2 studies examined the effects of TH immediately after arrest. The data indicated that hypothermia decreased in-hospital mortality and reduced poor neurological outcomes. Subsequent studies concur. The American Heart Association and the International Liaison Committee on Resuscitation endorsed TH in cardiac arrest patients. New technologies provide the best method for temperature control. Therapeutic hypothermia is standard of practice in many hospitals.

Description of Methods: A literature review was also conducted using the Cochrane Library, CINAHL, and AHRQ. Protocols from other institutions were also reviewed. From the data collected, a draft protocol was established. The protocol was reviewed by physicians, pharmacists, nurse managers, staff nurses, and a clinical nurse specialist. The final protocol and order set were presented to the medical management committee for approval. Staff and physicians were educated on the protocol.

Findings/Outcomes: In April 2010, a TH protocol was instituted. A pilot study, using a cooling device and traditional cooling blanket methods, with a total of 9 patients demonstrated good outcomes. Three patients were discharged to home with no neurological deficits, 4 patients had care withdrawn, and 1 patient died. At this time, 2 patients remain inpatient with minimal neurological deficits.

Conclusions: The data collected support the evidence that TH provides neurological protection for patients experiencing cardiac arrest.

Implications: Therapeutic hypothermia requires diligent nurses who assess for early signs of complications. Future studies are needed to examine length of times for cooling, rewarming, and maintaining normothermia. Therapeutic hypothermia needs to be studied on different neurological patients, such as stroke, intracranial bleeds, and drug overdose comatose patients to determine the effects of TH.

To the Rescue: Noninvasive Positive Pressure Ventilation (NPPV) Outside of the Intensive Care Unit

Rhonda Vincent, MSNc, RN, CCRN, East Carolina University, Raleigh, North Carolina

Purpose/Objectives: The purpose of this educational program is to introduce rescue noninvasive positive pressure ventilation (NPPV) to non-intensive care units (ICUs) that have not traditionally initiated and maintained this therapy.

Significance: After implementation of this program, patients requiring NPPV remained on the units, decreasing the necessity for ICU transfer. Additional benefits included professional development of nursing staff and cost savings related to changes in bed allocations.

Design/Background Rationale: The goals of this program were to (1) review the patient populations who benefit from NPPV therapy, (2) create a nursing policy to guide admission/transfer criteria, and (3) provide staff nurses the opportunity for "hands-on" ventilator time, increasing competency and comfort.

Description of Methods: A team composed of a clinical nurse specialist (CNS) student, respiratory therapist, and unit managers reviewed the literature for best practices. The team identified units that could safely care for patients using NPPV based on competency levels of the nursing staff, monitoring capability, and ability to provide an appropriate nurse-to-patient ratio. Five units were identified: 3 cardiac intermediate units, surgical step-down, and neurosurgical step-down. Educating staff was critical to successful implementation of the NPPV program. It was essential that nurses feel comfortable assessing the patient, utilizing the ventilator, and monitoring for problems-all new skills for most. To accommodate learning needs, a variety of activities occurred. Resource manuals were created, and face-to-face in-services were developed and conducted by the CNS student in collaboration with the respiratory therapist supervisor. Didactic review, hands-on practice with the ventilator, and emergency management discussion was included. Finally, our respiratory care department was coached in providing support for the nursing staff during this new skill acquisition.

Findings/Outcomes: Evaluation occurred using pretest and posttest modality. Of the 171 nurses attending the educational sessions, 160 passed the posttest. Patient outcomes were tracked for 4 months after implementation, during which 12 patients required NPPV. Eight patients were stabilized, and 4 patients required transfer to ICU.

Conclusions: Program implementation demonstrated an estimated cost savings of $6848/day. Noninvasive positive pressure ventilation review and competency are performed annually on all participating units.

Implications: The CNS student acted in the role of collaborator, educator, and change agent with an interdisciplinary team to facilitate effective program implementation.

Validation Study of Competencies for Clinical Nurse Specialists in Emergency Care

Kathleen Zavotsky, Seton Hall University, East Brunswick, New Jersey

Purpose/Objectives: The purpose of this study, conducted by the clinical nurse specialists (CNSs) in emergency care work team, was to create and validate core competencies for CNSs in emergency care. The competencies built on the foundational generic core competencies for CNSs developed by the National Association of Clinical Nurse Specialists.

Significance: The CNS in emergency care utilizes the foundational core competencies and additional competencies for the emergency care setting.

Design/Background Rationale: The design consisted of a validation process followed by a stakeholder meeting and a survey for validation.

Description of Methods: Initially, the CNSs in emergency care work team created an initial list of 43 competency statements. These preliminary statements were sent to 31 CNSs in emergency care for comment through 2 rounds of review. Based on their feedback, the list was reduced to 33 competency statements. A meeting with 12 stakeholder organizations was held to gain consensus on the competencies. Feedback from stakeholders and the resulting list of 28 competencies were validated with a national sample of 119 CNSs in emergency care. The participants rated each statement based on the importance of the competency for their practice and how frequently they perform the competency.

Findings/Outcomes: Data were analyzed for the responses to each of the 28 competency statements. The competency categories were as follows: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision making, moral agency, and advocacy. A competency statement was included in the final list if (1) at least 80% of participants rated 4 or more on importance and/or (2) at least 50% of participants rated 4 or more on frequency. Of the 28 competencies rated, 23 received ratings that met the criteria for inclusion in the final list. The work team discussed feedback and ratings of the remaining 5 competencies and determined that 2 would be included, resulting in 25 statements in the final list of competencies for CNSs in emergency care.

Conclusions: This research provides the necessary validation of competencies for CNSs in emergency care.

Implications: The competencies should serve as the foundation for CNS educational programs and for current and future entry-level practice for CNSs practicing in emergency care.