Ambulation at 3 Versus 6 Hours Post-Femoral Artery Hemostasis in the Percutaneous Coronary Intervention Patient

Warfield, Karen T, Mayo Clinic, Minnesota

Objective: To investigate the (1) patient's perceived back pain, (2) overall discomfort related to bed rest, and (3) the safety and efficacy of reducing the duration of post-PCI bed rest from 6 to 3 hours.

Significance/Background: Prolonged bed rest after femoral artery sheath removal following percutaneous coronary intervention (PCI) is associated with discomfort. Previous studies have shown that reducing bed rest time after coronary angiography reduces discomfort without increasing complications, but the effect of reducing bed rest in to less than 4 hours in post-PCI patients who have received significant anticoagulation and received GP IIb/IIIa inhibitors prior to PCI has not been adequately studied.

Methods: Two hundred forty-nine patients, including those receiving GP IIb/IIIa inhibitors, undergoing PCI utilizing 5F or 6F sheaths from the femoral access site were randomized to either 3 (n = 127) or 6 hours (n = 122) of bed rest. Perceptions of back pain and over-all discomfort were measured by the McGill Pain Questionnaire-Short Form and the visual analog scale.

Findings/Outcomes: At 3 hours after hemostasis, 30% of all patients had at least 1 verbalization of pain since sheath removal and 28% required analgesics, with similar proportions in both treatment groups. Six patients developed a hematoma > 5 cm. From 3 to 6 hours after hemostasis, 21% of patients verbalized experiencing pain on 1 or more occasion, and 16% required analgesia. Patient randomized to 6 hours of bed rest experienced significantly more pain: visual analog scale (P = .005), the Pain Rating Index (P = .003) and the Present Pain Index (PPI) (P = .015). One patient (randomized to 3 hrs bed rest) had a hematoma at this point. After ambulation a hematoma >5 cm was observed in 1 patient in each of the 2 treatment groups (P > .99). Rebleeding occurred in 2 (1.6%) of the patients who had 3 hours of bed rest, compared with 1 (0.8%) of the patients with 6 hours bed rest (P > .99).

Conclusions: Bed rest time following PCI via femoral access using 5F or 6F sheaths can be safely reduced from 6 to 3 hours with improvement in patient comfort. Further studies are needed to extend these results that early ambulation may be a safe alternative to prolonged bed rest for a subset of PCI patients.

Implications: With the results of this research study a standardized practice change was implemented across the institution minimizing the length of bed rest post-PCI. Patients verbalized increased satisfaction with early mobility as well as a decrease in complaints of overall discomfort. With the earlier mobility dismissal from the hospital was also obtained sooner.

An Electronic Decision Support Rule for Identification and Automatic Ordering of Heart Failure Education

Schad S, Chua Patel C, Griebenow L, Loth A, Mayo Clinic, Rochester, Minnesota

Problem: Providing heart failure (HF) discharge instruction is 1 performance metric that is required by Centers for Medicare & Medicaid Services. These metrics are publicly reported, are tied to reimbursement, and are within the domain of Nursing. Patients with HF often have multiple co-morbidities. These complex patients may be found on multiple units throughout our hospitals. Inpatient nurses are challenged to identify these patients in efforts to provide quality patient care and prepare the patient for self-care after discharge. Despite multiple education sessions given to nurses regarding importance of HF discharge instructions, metric defects continue.

Design: A team led by clinical nurse specialists, and an Informatics Nurse Specialist, explored a systematic way to assist nurses to identify the patients with heart failure, validate diagnosis with the team, educate, and document HF discharge instructions. The team designed an electronic decision support tool (Echo and Auto-order Blaze Rules) that auto-orders required education, if the patient records indicate: (1) left ventricular ejection function <40% per echocardiogram and/or (2) diagnosis of HF on the patient problem list. The rule initiates when a nurse opens the plan of care. When HF is on the problem list, a pop up alert is presented to the nurse noting, HF education was automatically ordered. The nurse then completes and documents HF education per discretion of the nurse.

Description of Methods: Four nursing units were piloted in this quality improvement project: medical telemetry cardiology, medical oncology, vascular telemetry and a medical neurology unit. The team met with pilot units' leadership to introduce the project, answer questions and gain support. Metrics were identified and the team met weekly to review reports and validated functionality of the rule. Feedback was given to the pilot units on a weekly basis. After the 4 week pilot, nurses were electronically surveyed to gain understanding of their workflow and usability of the rule.

Findings/Outcomes: The Echo Blaze rule was triggered in 402 patients. The Auto Order Blaze Rule was triggered in 341 patients. HF discharge instructions were not completed on approximately 3 discharged patients. There was a 48% response rate to the nurse survey (n = 127). The nurses were highly satisfied with the Blaze Rules as they served as an automatic reminder to complete HF discharge instructions. One problem identified was duplication of HF education orders.

Conclusions: Nurses found the decision support rule for HF was successful in reminding them to provide HF discharge instructions when appropriate. It is 1 system enhancement to promote and improve compliance with the core measure. Heart Failure Discharge Instructions.

Implications: HF metric defects for patient discharge instructions occur over numerous nursing units. HF decision support rules are 1 method nurses can utilize in assisting with identifying HF patients when they are in the hospital with multiple comorbidities. This identification approach for the multidisciplinary team enhances the ability to meet this metric and may be transferrable in meeting similar requirements in other chronic conditions.

An Evaluation of the Use of Mock Code Skills Stations in the Neonatal Intensive Care to Increase Nursing Confidence During Code Situations

Holub PA, Rady Children's Hospital, San Diego, California

Purpose: The purpose of this project was to evaluate nurses' confidence levels during code situations by reevaluating the use of neonatal mock code skills stations, and to compare the results of last year's data to the data collected this year.

Significance: JCAHO has recommended that institutions implement team training, clinical drills, and debriefings to alleviate problems during codes. The neonatal intensive care unit (NICU) mock code committee developed a model to improve nurses' confidence during code situations. The training model that resulted in increased nursing confidence during codes in the NICU is now a hospital wide initiative to increase the number of mock codes, and establish mock code skills training.

Design: The mock code skills stations were designed to provide neonatal nurses with education related to code situations. Each skills station was designed to focus on a particular nursing responsibly during a code. The theory being that practicing these skills will increase the confidence level of the nurse during a code.

Methods: The NICU unit based mock code committee developed and facilitated the mock code skills stations. During the course of a week nurses rotated through 4 mock code skills stations, and were then signed off on a mock code competency. A pre and post Likert-like scale self-assessment questionnaire was used to determine the nurses' confidence level both before and after attending the mock code skills stations.

Outcomes: A total of 104 neonatal intensive care nurses participated in the mock code station self-assessment. The results of the pre- and post-self-assessment questions were analyzed using the Wilcoxon signed rank test. The data analysis showed that the mock code skills stations increased nurses' confidence in their skills.

Conclusions: The results of the mock code station self-assessment showed that the participants continue to feel more confident after participating in mock code skills stations. After the development of the NICU Mock code committee the number of unit based mock code has increased.

Implications: The use of mock code skills stations are a valuable training tool, and can be used to increase the confidence of nursing staff during a code. The mock code skills stations in the NICU have been utilized as the framework for hospital wide mock code training. Within the next few months we plan to incorporate high-fidelity code simulations in the NICU, and continue to measure the nurses' confidence levels. The unit CNS will use this data to assist the unit based mock code committee in reevaluating the education plan. The unit based mock code committee will continue and provide additional training for the neonatal nursing staff.

An Innovated Approach to Optimizing Adolescent Transition to Adult Healthcare

Cerns SA, Froedtert Hospital, Milwaukee, Wisconsin; Rich C, Medical College of Wisconsin, Milwaukee; McCracken C, Froedtert Hospital, Milwaukee, Wisconsin

Significance: Unique challenges exist for young adults with sickle cell disease (SCD) transitioning their healthcare from pediatric to adult care environments. Key challenges include moving from family-centered care to patient-centered care; social and financial independence; navigating a complex healthcare system and anxiety related to new healthcare providers.

Background: Pediatric to adult transition issues are well published in current literature. Targeted transition programs for young adults living with chronic disease support structured transition plans. In a large academic medical center, young adults with SCD transitioning care from a children's hospital expressed strong concerns in understanding of responsibilities, expectations, and ability to navigate an adult healthcare setting. Additionally, healthcare providers expressed challenges related to inadequate preparation for young adults being admitted to the adult hospital.

Design: An academic medical center interdisciplinary team collaborated with a children's hospital in developing a young adult transition program. The program focuses on principles of self-management, expectations and responsibilities as an adult. Other interventions included a tour of the emergency department (ED) and inpatient unit. During the tour, various disciplines share information regarding individual roles and services that can be provided to the young adult during an inpatient hospital encounter.

Outcomes: The young adults and families/significant others reported that the transition program positively impacted them. They reported less apprehension in entering an adult healthcare system, were able to verbalize their responsibilities as a patient and expressed they have a better understanding of what to expect during an inpatient stay. Adult healthcare staff had the opportunity to participate in the tours and shared significant value in the transition program as well as gratitude to build relationships and influence the outcomes of their care.

Implications: Improving clinical outcomes and the patient experiences among young adults through a targeted transition care program offers an opportunity to communication, handoff and interdisciplinary collaboration in an adult healthcare setting.

An Innovative Approach to Certification Preparation

Kitchens JL, Hull MA, Wishard Health Services, Indianapolis, Indiana

Purpose: The purpose was to implement and evaluate an institutionally-based CNS-led medical-surgical preparation course in order to prepare its medical-surgical nurses to become certified.

Significance: The CNS competencies provide a basis for a CNS-led medical-surgical preparation course. Nursing certification may have many benefits to organizations including improved nursing competence, confidence, patient care, promotion of professional growth, and reflection of knowledge and expertise in a specialty.

Design: There is no formal medical-surgical certification preparation course at the institution. This course was requested by practicing medical-surgical nurses and organizational leadership. The approach to certification preparation was innovative by being institutionally-based for its own nurses eliminating cost of tuition and travel. Magnet recognition and career ladders elevate the importance of attaining nursing certifications. Clinical nurse specialist facilitation of certification preparation courses has received little attention in the literature.

Description: Two CNSs collaborated to implement and evaluate the medical-surgical certification preparation course by: planning each preparation session, advertising, developing novel instructional materials, acquiring study resources, fostering a safe learning environment, analyzing evaluation data, disseminating findings. Topics included in the review course were: navigating certification Web sites, identifying testable material, cultivating study skills, deciphering test questions, identifying perceived barriers to studying/learning, addressing known areas of weakness, decreasing test anxiety, test taking and study tips. Participants' knowledge was assessed by administering a 10-question pretest and posttest covering certification test content. The CNS-led medical-surgical certification preparation review course was evaluated by administering a CNS-designed Certification Preparation Course Survey consisting of a presurvey (12 items) and postsurvey (16 items) to assess overall course effectiveness.

Outcomes: The medical-surgical certification preparation course included 5 sessions (1.5 hours each) over a 6-week period (n = 6 nurses). Pretest results were 38%; posttest results were 84%. The Certification Preparation Course Survey results were positive. For the survey item, "I plan to take the medical-surgical nursing certification exam," results were yes (n = 5) and maybe (n = 1). Perceived degree of anxiousness when taking a test was measured using a 4-point Likert scale (higher scores equaling more anxiety). Mean perceived anxiety scores were presurvey (3.0) and postsurvey (1.7). All participants reported learning additional content, content presented was valuable, presenters and teaching methods were effective, practice questions were beneficial, personal goals were attained, course expectations were met, and the environment was conducive for learning.

Results indicate a CNS-led medical-surgical certification preparation course was an effective approach to enhance knowledge about medical-surgical content. Clinical nurse specialists should plan to conduct additional on-site courses and recruit more nurses to participate.

Implications: Additional demographic data should be collected including the number of participants who obtain certification within 1 year. Longitudinal evaluation strategies should assess overall cost-effectiveness and participants' retention and use of knowledge.

An Innovative Preceptor Model for Newly Hired Nurses to a Medical-Surgical Unit

Rape CR, Carolinas Medical Center, Indian Trail, North Carolina

Significance: Clinical nurse specialists can be a primary resource in the development of innovative, cost-effective orientation programs. Jones (2005) reported the costs of nurse turnover ranged from about $62 000 to $67 000 per nurse. Retention rates are often lower than national benchmarks among the medical-surgical nursing population and the cost of turnover is high. One medical center case study has described the largest cost driver of turnover as the loss and necessary replacement of nurses (Waldman et al, 2010). Costs associated with an orientation program include orientees' time, preceptor's time, and educator time.

Background: A survey of vacancies and turnover rates in 2000 revealed a 21.3% turnover rate for RNs in the hospital setting, with an average vacancy rate of 14.1% in medical-surgical care units. National nursing turnover rates are averaging 15% (MacKusick and Minick, 2010). In 2009, the turnover rate in this specific nursing division was 7.8%. In addition, historically, Orientees had not been highly satisfied with the orientation process. The goals for this quality improvement initiative included decreasing the cost of orientation by 20%, increasing the overall quality of nursing care by 5%, maintaining turnover rates < 10% and to have 90% of the Orientees rate their orientation excellent or very good on a postorientation survey.

Methods: The continuous quality improvement methodology used for this project was plan, do, study, and act. A new orientation structure was implemented that included an innovative preceptor model. Historically, preceptors have 1 orientee; oversee the orientee's patients while also having their own patient load. With the new model, the preceptor has 2 orientees, oversees the patients they have, and has no patients of their own. While the orientees progressively work up their patient load, the preceptor is able to focus, educate and work with the orientees one-on-one to lay the foundation needed for the orientees to be successful. This model contains benefits for the orientee, the preceptor, and for the unit while also enhancing clinical efficiency.

Outcomes: The cost for orienting 2 newly hired nurses was reduced by >20% while turnover rates remained < 10%. Overall quality of nursing care among the division had an 11% increase from the previous year. Ninety-two percent of the newly hired nurses rated their orientation excellent or very good on the postorientation survey.

Conclusions/Interpretations: An innovative approach to precepting new nurses may help reduce costs while improving nurse satisfaction and retention rates. Having lower turnover rates and a successful orientation program may also have a positive impact on patient satisfaction with overall quality of nursing care.

Implications: This preceptor model is a new idea and a new method for orienting new nurses. This innovative approach to precepting new nurses to medical-surgical units influenced efficiency, nurse retention, overall quality of nursing care and nurse satisfaction with orientation. The CNS has the clinical expertise to explore and evaluate the impact of new models of precepting and orientation.

An Innovative Reallocation of Resources to Reduce Pressure Ulcers in the Cardiovascular Intensive Care Unit

Freeman RK, Maley K, University of Michigan, Ann Arbor

Purpose: Rates of unit acquired pressure ulcers in the cardiovascular intensive care unit (CVICU) on the monthly skin prevalence day were above the national benchmark at an average of 13.99% unit acquired pressure ulcers per month from August 2011 to March 2012. Most commonly sacral, coccyx, buttock, and heel pressure ulcers were identified in the high-risk postoperative CVICU patients. To reduce pressure ulcer rates a plan was created to reallocate resources in the CVICU to focus on turning, positioning, and mobility.

Significance: Pressure ulcers are considered a "never event" by regulatory bodies and the development of pressure ulcers has significant adverse financial and safety effects on patients and institutions. Pressure ulcers treatment costs range from $2000 to $40 000 and contribute to increased length of stay, morbidity, and mortality. Pressure ulcers also cause increased pain and suffering for patients and families

Background: Cardiovascular intensive care unit is a 24-bed ICU with high-risk cardiovascular, thoracic, vascular surgery patients. The patient population includes coronary bypass grafts, valve replacements and repairs, aortic dissections and aneurysms, heart and lung transplants, espohagectomies, mechanical circulatory support, and extracorporeal membrane oxygenation. Many patients are at high risk for pressure ulcers due to the following: age, long operating room times, moisture, friction, shear, body max index, malnutrition, vasopressor requirements, heart failure, poor perfusion, and history of pressure ulcers.

Description: The literature was researched for current evidence-based practice related to reducing pressure ulcers. After implementation of a preventative dressing preoperatively pressure ulcer rates decreased, but select high-risk patients continued to develop pressure ulcers after complex stays the CVICU. After looking at current staffing ratios and functions, it was determined that a reallocation of resource was needed. The unlicensed assistive personnel (UAP) role was transitioned to a turning, positioning, mobility and oral care team rounding the unit every 2 hours. During these rounds the UAP reposition the patient, complete a skin assessment, apply preventative products, mobilize the patient, or provide pressure point relief it the patient is in the chair. The UAP would also provide oral care and document the position change and notify the nurse if the patient exhibits any sign of skin breakdown.

Outcome: After implementation of the new UAP role in March 2012 skin prevalence day data for pressure ulcers has improved. From March to present the average number of unit pressure ulcers identified on skin day was 6.9%. Of these ulcers 1 was lip, 2 were sacral, coccyx, buttock and 0 were heel ulcers.

Conclusion: A reallocation of resources utilizing the UAP as a turning, repositioning, mobility, and oral care team can reduce unit acquired pressure ulcers. Rates of sacral, coccyx, buttock and heel pressure ulcers rates can be reduced with consistent vigilant attention to turning, repositioning, and mobility practices.

Implications: Reallocating resources of the UAP in the CVICU has improved pressure ulcer rates and allowed the UAP a focus to champion on the unit. The prevention of pressure ulcers improves patient outcomes and reduces financial impacts.

An Interdisciplinary Team Effort to Increase the Number of Stroke Patients Who Receive Dysphagia Screening

Brumfield VC, Hersey M, Tillman M, University of Texas Medical Branch, Galveston

Purpose: The purpose of this project was to increase the percentage of acute stroke patients who receive dysphagia screening prior to oral medication and nutrition.

Significance/Background: Approximately 700 000 patients are diagnosed with stroke each year. Dysphagia is a common problem in stroke patients and is associated with serious complications, prolonged length of hospital stay and increased mortality.1 Diagnosis and evaluation of dysphagia is important and involves clinical assessments. The percentage of acute stroke at UTMB who received dysphagia screening prior to oral medication and nutrition did not meet the standard of care established by the Stroke Steering committee.

Methods: An interdisciplinary team of stake holders were gathered to address this problem. This included a neurologist, speech pathology supervisor, clinical nurse specialist, and staff nurses. when we began to develop documentation for the electronic medical record (EMR) we included an information systems analyst, nursing program manager and informatics specialist. A protocol was developed guiding both physicians and nurses when to do a dysphagia screen, how to do the dysphagia screen and how to document the results. A series of education programs were implemented to train nurses from each unit and then a more focused training sessions occurred with those nurses most likely to care for acute stroke pts. Both concurrent and retrospective audits were conducted to ensure compliance with the dysphagia protocol.

Findings: Prior to the implementation of a specific dysphagia protocol, the screening compliance was approximately 37.4% (December 2010). After the implementation of the protocol it increased to 84% (December 2011). We are trying to hold our gain but as of April 2012 we are at 75%. The percentage would be higher but some nurses screened the patients and did not assure the patients were kept NPO if they failed the dysphagia screen.

Conclusions: We have not met our target goal of 85% but continue to work with IS to establish reminders when a patient fails the dysphagia screening. We also increased our education efforts to include our HUC's and PCT's asking them to help nurses be vigilant about who received diet trays.

Implications: Improving our quality of care for stroke patients helps us move 1 step closer to our goal of stroke certification. We continue to strive for excellence with a goal to prevent complications that prevent our patients from being discharged to the highest level of care possible.

The Application of Interprofessional Education Using Simulation to Foster Learning and Collaboration Between Nursing and Medical Students

Scherer Y, University at Buffalo, The State University of New York

Significance: The Institute of Medicine (IOM) notes that lack of interprofessional cooperation and ineffective communication adversely affect best practice and improved patient outcomes. The IOM report suggests that by improving interprofessional efforts which include the development and evaluation of interprofessional education (IPE) models reflecting best practice, patient errors could be greatly reduced and patient safety improved (The Institute of Medicine, 2010). The CNS as researcher and educator is in an ideal position to evaluate IPE models and implement those reflective of best practice in both academic and healthcare settings.

Design: The purpose of this quasi-experimental study was to investigate the application of interprofessional education (IPE) with an innovative teaching strategy using patient simulation to support learning and collaboration between nursing and medical students in an education setting. Most students in healthcare professions, including nursing, are taught core content, values, and skills in isolation or "professional silos" which do not foster collaboration. IPE is considered to be an educational strategy that fosters shared learning and has the added potential benefit of improving teamwork, cooperation, and collaboration in practice, leading to improved patient outcomes. A growing body of literature is supportive of simulation's role in fostering collaboration among health science students, especially in nursing and medicine. Studies using simulation as a means to foster interprofessional collaboration have been reported in the literature.

Description of Methods: A quasi-experimental pretest/posttest design using an experimental and a control group was used to study the effect of interprofessional (senior nursing students and second year medical students) compared with intraprofessional (senior nursing students) simulation on knowledge, confidence, readiness and attitudes toward interprofessional learning (as measured by the Readiness Interprofessional Learning Scale), and attitudes toward working with healthcare teams (as measured by the Attitudes Toward Health Care Teams Scale), as well as satisfaction with the simulation experience. Eighty-four nursing students and 23 medical students participated in a high-fidelity simulation, cardiac arrest scenario.

Findings/Outcomes: The findings from this study support the value of interprofessional education using simulation as an educational strategy to improve students' attitudes toward learning with students from other disciplines, as well as the importance of teamwork. These findings were supported in the Readiness Interprofessional Learning Scale pretest and posttest scores for the nursing and medical students in the experimental group. Both groups' readiness for interprofessioanl education increased. An increase in knowledge was another positive outcome of the interprofessional intervention.

Implications: The CNS needs to consider the use of simulation as a teaching strategy for nurses to promote teamwork and collaboration within an interprofessional education framework.

Bed Rest Time After Removal of Femoral Artery Sheath: Evaluation of Optimal Time in Outpatient Adult Patients Having a Diagnostic Heart Catheterization

Murphy Gardner F, East Alabama Heart and Vascular, Auburn, Alabama

Purpose: The purpose for this project focused on determining the optimal length of bed rest time following an outpatient diagnostic heart catheterization using femoral artery access in adult patients (aged 18 and older). Goals for the project included implementing a safe change in practice without increasing complications.

Significance: Cardiovascular disease remains the leading cause of death in adult men and women. Of all deaths in 2006, 1 in every 2.9 deaths (56%) was related to cardiovascular disease. Heart catheterization is considered the gold standard in diagnosing coronary artery disease and accurately identifies specific areas of coronary artery disease.

Design (Background/Rationale): Diagnostic heart catheterization continues to be the standard test for the definitive diagnosis of coronary artery disease. Because of reduced reimbursement for arterial closure devices, many facilities are returning to the standard of manual compression for hemostasis of the arterial access. With the transition to manual compression, the staff in the outpatient cardiac catheterization lab of a large 300-bed hospital observed variable bed rest times for out-patients after a diagnostic heart catheterization. The staff, lead by a clinical nurse specialist (CNS) student, developed a chart audit tool in order to evaluate complications and patient demographic information associated with the complications.

Description of Methods: Researchers conducted a retrospective chart audit of consecutive cases during 1 month. Based on a review of existing evidence including a retrospective record review, a 2-hour bed rest was implemented for patients requiring a 5F sheath. After implementing the 2-hour bed rest, the team performed a second retrospective chart audit of consecutive patients for 1 month.

Outcomes: Following the standardization in practice, the CNS-student noted an overall reduction in complications. Of the 132 patients, 9 (6.8%) experienced some form of complications. Again, some patients had more than 1 complication. Following the standardization, 2 (1.5%) patients complained of pain during bed rest, 2 (1.5%) had a hematoma prior to bed rest, 1 (0.75%) patient experienced bleeding before bed rest, and 1 (0.75%) patient had a vagal episode during their hold time. The remaining complications included 1 (0.75%) patient with a hematoma and bleeding at ambulation and 2 (1.5%) patients who had a vagal response at ambulation. Analysis of the patients with complications revealed 3 females and 6 male patients. Age ranged from 53 to 79. Weight ranged from 59.7 kg to 97.2 kg. The average weight of patients with a complication was 75.1kg (165 pounds). Six patients with complications took Aspirin and Plavix before the procedure.

Conclusions: Standardization in bed rest time resulted in a decrease in the average bed rest time from 135 minutes to 130 minutes. Average length of stay decreased from 416 minutes to 402 minutes. Complication rates remained low at 1.5% following the decrease in bed rest time.

Implications: While the average bed rest time decreased by only 5 minutes, the total number of patients with a bed rest of 1 to 2 hours increased from 77.7% to 88%. More patients ambulated safely at 2 hours without an increase in complications. Shorter bed rest time results in greater patient satisfaction with their procedure.

Bloodstream Infection: Educating Emergency Department Staff About Central Line-Associated Bloodstream Infections

Young G, Chamblee T, Children's Medical Center, Dallas, Texas

The etiology, prevention, and treatment of central line-associated bloodstream infection (CLABSI) have been critical issues for inpatient units for years. Because the Centers for Disease Control requires surveillance of central line-associated infections in inpatient areas, bedside nurses, educators and CNSs in these areas are acutely aware of terms such as catheter-associated infections, line days, bundles and biofilm. Discussions of central venous catheters during bedside rounding are common practice. Conversely, many non-inpatient areas such as emergency departments (ED), radiology or operating rooms (OR) though educated on basic care and handling of central venous catheters, have not traditionally been included in the expanded education and bundles for care. Surveillance is not required for CLABSI in non-inpatient areas, yet they still often insert and access all types of CVCs. This was the case for our pediatric emergency department. We did not have statistics linking CLABSI to the care of patients coming through our department. However, feedback from inpatient units, and patients/families who had attended our ED revealed that our practices with CVCs were not consistent. Patients/families expressed uncertainty in the expertise of the ED staff. In response to this issue, the ED CNS in collaboration with experts within the institution developed a program designed to increase ED nurse's expertise related to knowledge of CLABSI and care of CVCs. The program includes 4 hours of didactic learning, skills stations, and videos of parents relating their experiences in the ED. In addition, each nurse spends a total of 8 hours on 2 inpatient units interacting with staff, learning about CVC bundles, and caring for patients with CVCs. Twenty-one nurses have now attended the program. Written tests and audits of documentation serve to monitor knowledge and compliance. These nurses are now "clinical resource nurses" for the care of the CVC in the ED, and they serve as experts on the unit for care and trouble shooting. Feedback from ED staff and from the inpatient units has been overwhelmingly positive. Though CLABSI data cannot be tracked through the ED, we are working with infection control to explore other options. Our goal is improved patient/family experiences and plans are underway to collaborate more closely with families in the future. Hospital-associated infections decrease with use of evidence-based practices. The education and monitoring of those practices should include all areas of the hospital. Strategies for education have included collaboration between the ED and areas with expertise in the care and treatment of CVC, and the creation of "clinical resource nurses" to serve as experts for high-risk patient groups. These methods have great potential to enhance patient care and improve outcomes, as well as further develop relationships between patient care areas.

Bullying in the Workplace of Nurses

Turi SK, St Vincent Hospital, Carmel, Indiana; Ziemba-Davis M, St Vincent Hospital, Indianapolis, Indiana

Purpose: The purpose of this study was to identify the prevalence of bullying experienced by nurses and who engages in this behavior at an 800-bed quaternary care hospital located in the Midwestern United States.

Significance: There is growing evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, and conflict and stress among nurses. Documenting whether nurses experience bullying and possible variations based on demographic characteristics are the first step to addressing and stopping the behavior.

Background: Research indicates as many as 57% of nurse's world-wide have experienced bullying in the workplace. The World Health Organization defines bullying as "repeated and over time offensive behavior through vindictive cruel or malicious attempts to humiliate or undermine an individual or group of employees." As noted by The Joint Commission, quality and safe patient care depend upon a collaborative work environment free from intimidating and disruptive behaviors. While anecdotal wisdom holds that bullying among nurses is common, very few studies have actually quantified bullying among nurses in the United States.

Methods: Forty percent (n = 853) of all RNs and LPNs in the study institution anonymously completed an online questionnaire assessing the prevalence of 22 bullying behaviors and who engaged in the behavior (a nurse, physician, patient, etc). Additional questions addressed how bullying is perceived by and has affected nurses. Demographics included age, gender, education, position type, years of nursing experience, healthcare specialty/unit, and work shift. The questionnaire was based on extensive review of the literature identifying 22 behaviors previously documented as indicative of bullying. Institutional review board approval for the study was obtained.

Findings: Ninety-four percent of nurses had experienced 1 or more of the 22 bullying behaviors in the last 12 months. The average number of behaviors experienced was 8.7 (SD 5.6). The most common behavior (experienced by 77%) was having someone speak to or about you in a belittling or demeaning manner. The least common (experienced by 8%) was having someone suggest you are mentally unstable or psychologically unwell. The prevalence of bullying did not differ by demographics. In most cases, the "bullier" was another nurse. Nearly all nurses agreed that bullying negatively affects patient care. More than half reported that bullying has negatively affected them professionally and personally. Nonetheless, only 28% believed that bullying is a problem where they work.

Conclusions: This study documents that, consistent with anecdotal wisdom, bullying does occur in the workplace of nurses. Moreover, nurses themselves are the most likely to bully other nurses. The findings support existing theory that nurses inherently behave as an oppressed group and suggest that nurses believe bullying is acceptable behavior.

Implications: Clinical nurse specialists (CNSs) are charged with improving patient outcomes. The most successful do so by understanding the culture within which they work. The first author (a CNS), nurses, ethicists, and mission leaders in our organization are using this work in next steps to identify the underlying causes of bullying and enhance the work environment of nurses, thereby improving patient safety and well-being.

Burn Care Program: Building Clinical Competency for Air Force Critical Care/Emergency Nursing Fellows

Tubera D, US Army Institute of Surgical Research, San Antonio, Texas, and Savell K, US Air Force, Lackland AFB, Texas

Purpose: The purpose of this project was (1) to evaluate an educational program in conjunction with the US Army Institute of Surgical Research (USAISR) Burn Center to build clinical competency in burn care among US Air Force (AF) nurse fellows tasked to deploy overseas; and (2) to describe the multifaceted role of the clinical nurse specialist (CNS) in the implementation of the burn program.

Significance: Burn injury is a constant threat in a deployed military environment. Provision of burn care in an austere deployed environment is both challenging and demanding. It is a complex and resource intensive patient care need involving the multidisciplinary team process and requires competent burn care trained personnel to ensure optimal outcome. The CNS is uniquely positioned to use a multifaceted function in the development and implementation of an educational program to promote collaboration and facilitate learning.

Background: The critical care/emergency nursing fellowship is a year-long training program to develop an entry level Air Force (AF) critical care and emergency nurse. The nursing fellowship program is designed to identify educational elements that best prepare AF nurses for practice in the area of critical and emergency care. With nearly 100% deployment rate after fellowship completion, reports from past fellow graduates indicated they felt inadequately prepared to provide burn care in the deployed setting.

Description: Collaboration with USAISR burn unit leadership was done to establish a training agreement and education plan for the AF nursing fellows. Burn care curriculum was developed and composed of didactic class-3 hours of burn management, 2-day burn symposium; clinical hours-160 hours of supervised clinical rotation at USAISR burn center; and a competency checklist to assess and verify competency level in burn care. Nurse fellows started burn rotation towards the end of their fellowship program. The CNSs conducted daily clinical rounds to discuss patient status and evaluate nurse performance. Weekly conferences with all nursing fellows in the burn center were done to follow up on their clinical/learning experience. Continued collaboration with burn intensive care unit (ICU) wound care coordinators and CNSs provided opportunities to discuss learning needs of the nursing fellows.

Outcome: Thirty-eight competent AF critical care/trauma nurse completed the burn program; all have subsequently deployed overseas. Participants successfully completed a competency checklist of 144 burn-specific tasks.

Conclusion: Implementation of a burn care program provides increased competency in caring for burn ICU patients among AF nurse fellows. The responsible CNSs have the advanced knowledge and clinical expertise to lead the development, implementation, and evaluation of such a program. Ongoing collaboration with CNS educators in the burn center promoted the success of our burn program.

Implication for Practice: The burn injured ICU patients in the deployed setting have unique needs; preparing combat nurses with competent skills promotes optimal patient outcomes. The CNS possesses the knowledge and expertise to provide the education and assessment for nurses during predeployment training.

Can a Single Asthma Day Camp Improve Rural Children's Asthma Self-management?

Horner SD, The University of Texas at Austin

Purpose/Objectives: The purpose of this study was to examine the effects of an intervention delivered in a single asthma day camp on school-aged children's knowledge of asthma, self-reported asthma self-management behaviors, and their observed skill in using a metered dose inhaler.

Significance: Fully 9.6% of children under 17 years of age have asthma. It disproportionately affects more school-age boys than girls, and more racial/ethnic minorities than nonminorities. Because school-aged children are away from home for a large portion of the day, it is important that they learn to recognize and respond to early asthma symptoms. In rural communities where resources are limited, finding effective ways to deliver interventions or health promotion programs within the available resources is an important strategy for improving the health of underserved groups.

Design: Exploratory, descriptive study using data collected as part of a larger on-going longitudinal study testing asthma self-management interventions versus a health promotion intervention. The question of whether an asthma intervention can be delivered in a single comprehensive day camp and lead to changes in children's self-management behaviors is an important one that could potentially lead to broad dissemination across communities.

Methods: Sample inclusion criteria were children in grades 2-5 and who had a physician diagnosis of asthma. The setting is rural (non-metropolitan areas with no towns of 1300 population or larger). Children were randomly assigned to receive either asthma education in a single asthma day camp or to health promotion classes as a comparison intervention. Data were collected at the time of study enrollment (consent, assent, baseline data) and again 6 weeks after the intervention. Repeated-measures analyses of variance were run to compare the 2 groups on asthma knowledge and asthma self-management with data obtained at study enrollment and again 6 weeks after the intervention.

Findings: The sample was composed of 115 children with 78 boys (67.8%) and 37 girls (32.2%); and 60% Hispanic (H), 30% African American (AA), and 10% non-Hispanic white (W); and a mean age of 8.83 years. There were no differences between the camp and comparison group on asthma severity, asthma knowledge or asthma self-management at baseline-indicating the groups were comparable at baseline. Asthma knowledge significantly improved for both groups after the intervention (F = 18.06, P < .001). Asthma self-management behaviors did not change for the comparison group but improved significantly for the camp group (F = 5.729, P = .018). Furthermore, the children in the asthma camp significantly improved their skill in using a metered dose inhaler (F = 15.03, P < .001).

Conclusion/Implications: All of the children improved their asthma knowledge, even though the comparison group did not receive asthma education. It is possible that completing survey questions may have sensitized them to asthma information (ie, effects of repeated testing) but this did not lead to changes in behaviors for the comparison group. The significant improvements in asthma behaviors and inhaler skill of the asthma camp group, indicate that the asthma camp may be a viable means for delivering an asthma self-management intervention to school-aged children.

Caring for Adult Patients in a Pediatric Facility: Identifying Challenges and Recommendations for a Changing Healthcare Landscape

Torzone A, Chamblee T, Children's Medical Center Dallas, Texas

Objective: The purpose of this project is to appraise care needs of adult patients with chronic pediatric onset conditions requiring hospitalization in a pediatric facility.

Significance: Because of medical advancements, improved technology, and in some cases, an increase in disease prevalence, many individuals with diseases and/or conditions that were historically considered to be fatal in childhood are now surviving into adulthood. These improved patient outcomes create new challenges in healthcare. Because of the uniqueness of their condition, these adult patients often continue to seek care at pediatric hospitals. Pediatric nurses and subspecialists are not trained in the management of adult patients and their acquired comorbidities. Likewise, adult practitioners have very limited, if any, exposure to pediatric conditions. This presents a significant problem in the management of a unique patient population.

Design: There is a paucity of published literature on the care and management of the adult patient with a chronic pediatric condition requiring hospitalization. To identify content for an educational intervention, a needs assessment survey, developed by the researchers, was conducted. Based on the results, as well as, a review of the literature on the topic, an educational intervention will be developed and implemented.

Methods: The design for this project is an educational needs assessment survey followed by a 1-group pretest/posttest intervention. The population of interest is registered nurses specializing in pediatric critical care at the research site. A convenience sample will be used. The intervention will consist of information regarding the care needs of adult patients including normal parameters related to vital signs, laboratory findings, and electrocardiography, cardiac dysrhythmia management, adult comorbidities, body mechanics for lifting, informed consent/advanced directives, medication safety, emergency care algorithms, and communication strategies. The intervention will be provided in a series of four 4-hour classes. Final institutional review board approval is pending. Outcome measures include knowledge and nurse satisfaction. Knowledge will be assessed in a pretest/posttest fashion using a modified version of the Basic Knowledge Assessment Tool (BKAT-8) for adult critical care nursing. The researchers will extract specific items from the BKAT that tap into the content of interest. Reliability and validity of the modified tool will be tested prior to use in the study. Pretest/posttest nurse satisfaction will be assessed using the nurse satisfaction items on the Moorehead Employee Satisfaction Survey.

Findings: Preliminary results suggest that a practice change is needed and will likely contribute to improved patient care and improved satisfaction among nurses.

Conclusion: Adult inpatients in a pediatric facility are a low volume, high-risk population. Lack of knowledge about how to provide safe and effective care for these patients exists among pediatric nurses and providers. This knowledge gap may contribute to adverse events for patients and job dissatisfaction among pediatric nurses.

Implications: Implications of this practice innovation include identification of the care needs of a unique patient population and implementation of an educational intervention to address that need. To date, this has not been empirically tested. The study seeks to address this gap in knowledge.

An Innovative Clinical Nurse Specialist Competency Evaluation Program

Marder L, Donnelly J, Nasshan S, Toole B, Sharp Memorial Hospital, San Diego, California

Purpose/Objectives: This presentation will demonstrate how to implement an innovative annual competency program by recognizing the difference between competence and skills check offs, examining the various competency validation methods and identifying possible implementation barriers of a new competency validation program.

Significance: In today's economic healthcare climate, clinical nurse specialists must implement innovative methods to evaluate nursing competency as a means to preserve scarce education dollars.

Design (Background or Rationale): The clinical nurse specialists (CNSs) of 4 progressive care units (PCUs) in a mid-size southern California hospital decided to replace the traditional annual skills day with a modality of diverse evaluation methods to meet individual needs and learning styles. Each PCU leadership team, composed of a CNS, manager, clinical leads, and advanced clinicians, oversees the clinical competency of nursing staff. The CNS collaborated with their leadership team to select the most appropriate competency evaluation method taking unit culture into consideration. Competency evaluation methods utilized in this process were examinations, return demonstrations, evidence of daily work, case studies, on-line videos, exemplars, peer review, self-assessment, and mock events.

Description of Methods: The PCU CNSs met weekly to discuss logistics of the new competency process. The CNSs wanted to provide staff with the opportunity to choose between several methods for completing their annual competencies while on duty in the actual work environment. Each competency consisted of 3 options for completion, all of which provided an accurate reflection of current practice and autonomy in their practice. Because the competencies were to be demonstrated and completed during work hours, the specific options had to be simple yet effective for the learner. The PCU CNSs developed the specifics of the new program based on input from a needs assessment. Competencies were reviewed and case studies, reflective learning tools and clinical safety investigation rooms were created. Each nurse received an informational folder that included a section in which to document completion of competencies. A monthly schedule of competency evaluation was created and explained to nursing staff and included when each competency was to be completed. In addition to these competencies, an emergency standing orders standardized procedure "test" was administered while nursing staff were off-duty. Along with the test, a physician lecture was offered for another learning opportunity. The lecture topics were chosen from the staff self-identified needs assessment with the goal of improving the collegial relationship between physicians and nurses.

Findings/Outcomes: The new process for annual competencies produced a 600-hour reduction in education hour usage for annual competencies from 2011 to 2012. Based on the average RN rate of pay of $42.20 per hour, this program realized a cost savings of approximately $25 320.

Conclusions/Interpretations: The benefit of this innovative program is both financial and educational. Care quality is measured at the bedside. The new program allowed the nursing staff to demonstrate their competency via the method which they felt best exemplified their knowledge and skill.

Implications for Practice: Using a CNS-driven annual competency program saved education dollars for use in other areas deemed important by individual units.

Changing Vaccination Practices in a Children's Hospital

Hartman J, Cleveland Clinic, Ohio

Purpose: The Centers for Medicare & Medicare have mandated that pediatric patients be screened for high-risk conditions and immunized against pneumococcal and influenza disease prior to discharge, if indicated. The purpose of this project is to describe the implementation of a quick reference tool for pediatric nurses to order and administer the pneumococcal and influenza vaccines on inpatient pediatric units at a tertiary care hospital. The presentation will describe how an advanced practice nurse (APN), functioning as a CNS, was able to empower nursing practice by providing a tool that is quick and easy to use, while increasing professional confidence in administering the vaccine. The overall objective increased immunization rates and decrease missed opportunities, improving core measure outcomes.

Significance: The CNS role is the ideal position to effect practice change. Vaccines have been identified as one of the most important public health interventions in history. Everyday thousands of hospitalized patients from across the country could benefit from pneumococcal and influenza immunizations, yet few are actually given the vaccine.

Background: This presentation articulates how the APN functioning in the CNS role was able to promote and enable nursing to take ownership for screening, ordering and administering pneumococcal and influenza vaccines using a standardized process. Screening the patient would prove to be the most difficult part of the process. Pneumococcal vaccine was particularly anxiety producing due to the change in vaccine serotypes from 7 to 13 in the past 2 years and the addition of the Pneumovax vaccine to be administered to high-risk pediatric patients.

Description: It is an established concept that learners acquire knowledge in many different ways. There are auditory learners, visual learners and kinesthetic learners. The presentation will describe tools that are directed at visual learners, such as written directions and charts. These tools, developed by the APN allowed for rapid, accurate nursing assessment to determine whether the child is a candidate for the pneumococcal or influenza vaccine. The involvement of the CNS in reinforcing the decision prior to the actual electronic screening that is required resulted in decreased nurse anxiety and increased confidence in the implementation of the protocol.

Outcomes: Influenza season is just beginning for the 2012 influenza season. Nurse-driven pneumococcal screening, ordering and administering has taken place for the past 3 months. Results to date indicate a dramatic fall is immunization screening failures.

Conclusion: The screening, ordering and administering of vaccines is a complex process and changes from year to year. With increasing demands on nurses' time and complex patients with high acuity it is important to provide nurses with tools that will increase their understanding, decrease their anxiety and contribute to the over all well being of the patient.

Implications for CNS Basic and Continuing Education: As an educator, consultant, clinical expert and care giver clinical nurse specialists' influence outcomes by increasing quality and cost effectiveness of processes that provide support to nurses who provide direct patient care everyday. The unique articulation of the CNS role is critical to the success of the program.

Chest Tube Removal Post-Surgical Intensive Care Unit Transfer: A Practice Change for Cardiovascular Registered Nurses

Myrick J, Mayo Clinic in Florida, Jacksonville

Purpose: To instruct cardiovascular (CV) nurses in the removal of pleural and mediastinal chest tubes post-SICU transfer.

Significance: By preparing CV RNs to remove chest tubes there is the potential to change practice. In addition, it provides the opportunity to create a caring environment that may result in a positive patient experience.

Design: Cardiovascular (CV) nurses at this facility did not remove chest tubes (CTs) from coronary artery bypass graft (CABG) patients or thoracotomy patients. CTs were removed by the surgical intensive care unit (SICU) nurse prior to patient transfer to the cardiovascular unit or by the cardiothoracic surgical team (CTS). Removal by the CTS team was typically performed in the morning on their way to surgery. Often, patients were not prepared for removal via education, or analgesia. As a result, many experienced pain and anxiety that could have been avoided. One CTS surgeon suggested that CV nurses learn to remove CTs.

Description: This was a quality improvement project. Patient population included coronary artery bypass graft, heart valve, and thoracotomy patients with chest tubes in place after transfer from the surgical intensive care unit (SICU) to the cardiovascular unit. The CV clinical nurse specialist (CNS) developed a novel chest tube removal class. The 1-hour course included the following didactic elements: the history of chest tubes, thoracic anatomy and physiology, Jean Watson's Theory of Human Caring, instructions for safe chest tube removal and possible adverse events. Hands-on chest tube removal practice was simulated with the use of common drinking straws. The class concluded with a written test. Participants were required to complete a minimum of 3 observed chest tube removals by the CV CNS or CTS team before being checked off for independent removal.

Outcome: The 1-hour course was offered in January and February, 2011. Of the original 14 dayshift nurses who attended, 13 have become independent in chest tube removal. Informal survey of CV nurses indicates they felt adequately prepared to remove CTs and to create a caring environment. Patients have also responded favorably; most comments reflect that there has been little or no pain experienced during the procedure. Finally, providers have verbalized satisfaction with the new nursing skill. There have been no adverse events as a result of CV nurses removing CTs.

Interpretation/Conclusion: Data collection is still in progress; however, overall responses have been positive. The innovative chest tube removal course created by the CV CNS has allowed the CV nurses to acquire a new skill set. Furthermore, it has permitted them to create a caring environment by preparing the patient for a potentially uncomfortable procedure.

Implications for Practice: Research indicates that allowing the nurse to create a caring environment positively impacts job satisfaction and retention. This new practice change, once the domain of the SICU, has the potential to optimistically influence the nursing sphere. Likewise, patient satisfaction may be reflected in future Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores. Finally, all 3 spheres of CNS influence may be positively impacted.

A Clinical Nurse Specialist and Unit Educator Collaboration to Improve Clinical Staff Members' Resuscitation Skills

Janke E, Mahramus T, Orlando Health, Florida

Purpose: (1) Identify data that are needed to evaluate effectiveness of cardiopulmonary resuscitation practice drills on self-reported comfort with skills. (2) Describe the impact of clinical nurse specialist and unit educator collaboration on selected outcomes. (3) Illustrate the value of frequent practice drills in maintaining comfort with resuscitation skills.

Significance: Timely cardiopulmonary resuscitation efforts are imperative to improve patients' chances for survival. Research has shown that, if not utilized on a consistent basis, providers' knowledge, skills and confidence sharply decline within weeks of attending formal resuscitation training. The use of practice code drills has been reported to decrease anxiety and increase staff confidence and readiness to perform in emergency situations.

Background: The clinical nurse specialists (CNSs) collaborated with several cardiac clinical unit educators (CUEs) to develop a structured process to increase clinical staff members' resuscitation skills during cardiopulmonary arrests. All RNs and clinical technicians from 3 cardiac units were included in quarterly cardiopulmonary arrest practice drills.

Methods: All participants were given a self-evaluation form to grade (Likert scale 1-5, with 1 being the lowest and 5 the highest) their comfort with Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) skills preintervention and postintervention practice drills. Debriefing was done by the CNSs and CUEs postcode to provide feedback and to allow the participants to ask questions. Mean scores on the self-reported comfort level were compared preintervention and postintervention drill for each unit and again between each unit's quarterly scores. A tip sheet with rationales for why specific skills are necessary during resuscitation events was given to participants at the end of each session.

Outcomes: After 2 quarterly sessions an overall improvement in level of comfort was noted. First quarter predrill mean scores were 3.45 versus 4.00 postdrill. Second quarter predrill mean scores were 3.40 versus 4.14 postdrill. Participants consistently scored the following items lowest (pre-/post-): operation of the defibrillator (3.12/3.89); operation of the pacer (2.69/3.73); documentation during the code (2.94/3.61); leading a code until the Code Blue 90 team arrives (2.69/3.46); and leading a code even after the Code Blue 90 team arrives (2.63/3.44).

Conclusions: Biannual BLS and ACLS certification may not be enough to assist clinical staff with maintaining the skills necessary to resuscitation situations. Practicing code drills on a quarterly basis has demonstrated an improvement in participants' self-reported comfort with resuscitation skills.

Implications: The implementation of a structured process similar to this program may be beneficial to improve one's comfort with skills not performed on a regular basis. Practice resuscitation drills are being initiated on an outpatient chemotherapy unit and plans to include medical and surgical units in the future are being discussed. Further research is needed to determine if the results of the program have an impact on the outcomes of actual cardiopulmonary arrest situations occurring on these units.

Clinical Nurse Specialist Driven Strategies to Improve Transitions

Ventura K, Hucjs M, Hospital of the University of Pennsylvania, Philadelphia

Purpose: Identify clinical nurse specialist (CNS)-driven strategies to improve transitions from critical care to acute care to hospital discharge. Discuss CNS practices required to implement processes to improve transitions.

Significance: Increased scrutiny on hospital readmissions and focus on transitions, in addition to decreasing mortality, has become priority with the implementation of a value-based purchasing system. It is also well published that intensive care unit (ICU) readmissions are associated with increased mortality rates.

Background: Monthly review of readmission rates on a 29-bed transplant surgical unit revealed a large number of liver transplant patients being readmitted. Partnerships between the ICU CNS and acute care CNS led to further investigation and implementation of strategies to improve transitions in care for this complex patient population.

Description of Methods: Hospital and ICU readmission database was reviewed for all liver transplant recipients from July 2010 through June 2011. Descriptive analysis of readmission data conducted to explore factors associated with readmission. Case review of liver transplant patients readmitted to ICU conducted in order to identify common causes. Approximately 30% of these patients were readmitted within 30 days of discharge, a higher rate than the 20% all-cause readmission rate reported by Centers for Medicare & Medicaid Services. In addition, approximately one-third of liver transplant patients returned to the ICU during their hospitalization posttransplant.

Outcome: Clinical nurse specialists identified discrepancies between nursing and surgical provider team perspective of readiness for transfer from ICU to acute care unit including patient acuity, level of care, patient monitoring and physiologic stability. Similar differences in perspective were also revealed between the transferring ICU nurses and the receiving acute care nurses. Compromised respiratory and altered mental status were identified as the 2 areas of greatest clinical concern upon transfer and the most common reasons for transfer back to ICU. Guided by CNS, the ICU and acute care nurses partnered to create a tool to improve communication during transition from ICU to unit.

Conclusion: Increased hospital and ICU readmission rates for liver transplant population was not recognized as a problem until the CNS reviewed data and explored clinical experience. Strategies implemented in improved transitions for this complex patient population include a CNS-driven process developed in order to gather more data and identify factors specific to this patient population to prevent ICU readmission and a transition communication tool utilized by clinical nurses.

Implications for Practice: Clinical nurse specialist practice to investigate the problem, define and clarify the issues, implement and evaluate interventions is necessary to improve transitions for complex patient populations. Clinical nurse specialist ability to collectively approach an issue from the patient, nurse and systems perspectives is what guides the development of interventions appropriate to optimize outcomes.

Clinical Nurse Specialist Role in Decreasing Unplanned Device Removal in a Pediatric Intensive Care Unit

Christopher JA, Handwork C, Perebzak C, Akron Children's Hospital, Ohio

Purpose: To describe efforts by a multidisciplinary committee, led by a clinical nurse specialist (CNS), to reduce unplanned device removal (UDR) rates in a pediatric intensive care unit (PICU).

Background: The Institute of Medicine (2001) described 6 characteristics of high-quality healthcare systems, one of which is safety; another is efficient care to avoid waste. Any UDR is a patient safety risk due to the critical nature of many devices. Replacement of any accidentally removed medical device requires the use of additional resources, including personnel and equipment leading to increase cost.

Description: A longitudinal design was used to identify UDR rates in the PICU population. A medical/surgical PICU with 1500 annual admissions served as the setting. In 2009, we started to monitor UDR in our PICU. Devices monitored include endotracheal and tracheostomy tubes, nasogastric/nasoduodenal/gastric feeding tubes, central venous catheters, indwelling urinary catheters, and chest tubes. A CNS-led multidisciplinary Critical Incident Review Team (1) identified reasons for UDR, (2) monitored UDR using a standardized data collection tool, (3) conducted critical incident review of UDR in real time with nursing staff, medical staff, and the charge nurse, (4) reviewed events for the purpose of identifying/implementing improvement, and (5) provided staff education on measures to prevent UDR. In 2011, a spike in UDR rates occurred requiring implementation of performance improvement measures. In addition to real-time critical incident review, we implemented an additional level of "safety huddle" between nursing staff at change of shift. Various securement devices were trialed by staff. A guideline was created for safe moving and repositioning of patients. Parents received education on the necessity of having the nurse help with moving their child. For PICU staff awareness of UDR progress, a dry erase board was installed to display days since the last UDR event, and UDR rates were discussed at monthly PICU quality improvement meetings and monthly PICU staff meetings.

Outcome: In 2011, UDR rate spiked to 10.1/1000 device days from 2.2/1000 device days in 2010, despite improvement efforts. For the first 2 quarters of 2012, the PICU UDR rate decreased to 4.1/1000 device days.

Conclusions: Pediatric ICU critical incident reviews provide valuable information surrounding UDRs and allow for longitudinal tracking to direct improvement efforts. The multiple practice changes, guideline implementation and securement device trials, under the guidance of the CNS-led PICU Critical Incident Review Team has been instrumental in addressing patient safety and UDR in the PICU.

Implications for practice: The safety issue of UDR continues to be a problem in this PICU population. A CNS-led Critical Incident Review Team for review of UDR and implementation of education and evidence-based practices has led to a reduction in UDR rates thus far in 2012. Continued monitoring of UDR and improvement efforts are necessary to address patient safety and to conserve resources as safety and efficient care are 2 characteristics of high quality healthcare.

A Clinical Nurse Specialist's Role in Developing Strategies to Facilitate Early Transfer of Cardiothoracic Patients to the Intermediate Care Unit

Funari T, Brooke Army Medical Center, Saint Hedwig, Texas

Purpose: The purpose of this project was to enhance the care of the cardiothoracic patient population in the intermediate care unit (IMCU). The goals for this project consist of improving patient satisfaction, physician perception of nursing care, and nursing confidence by providing the nursing team with education and facilitating communication with physicians.

Significance: Coronary artery bypass graft (CABG) patients have special needs in the area of cardiac rehabilitation and with the astute clinical assessment, aggressive ambulation, and pain management they can meet their goal of wellness quickly and safely (Cebeci and Celik, 2008). It is imperative that nurses have the specialized knowledge required in order to provide the required care that will help the patients to reach their goals.

Background: Transfer of postoperative CABG patients from the ICU to IMCU has many challenges and risks. The care of complex patients requires a high level knowledge and competencies in order to progress the patient safely and timely toward discharge (St Louis and Brault, 2011). Because of the lack of expertise in caring for CABG patients, the comfort level of nursing staff at an IMCU was low. Additionally, surgeon's confidence regarding nursing care of this patient population was also low, causing surgeons to hold on to patients in the ICU much longer than then required. A workgroup was formed consisting of physician and nursing leadership, as well as, a CNS to develop a plan of action to increase the competencies of the nursing staff as well as improve communication with providers.

Methods: Forty-eight nursing and 7 physician staff were surveyed to determine their confidence level in the area of patient care and multidisciplinary communication. Twenty-seven percent of registered nurse reported confidence in caring for CABG patients and 18% reported good collaboration with providers. Six of the 7 providers rated nursing care as average but rated collaboration with nursing good. A multidisciplinary team identified that a collaborative approach to patient care and education was necessary to develop nursing competencies and decrease ICU length of stay. Methods of implementation were (1) a phased structured education plan, (2) a reservation system for CABG patients, and (3) detailed patient focused plan of care.

Outcome: A 60-day assessment revealed improvement in patient care as verbalized by physician staff and nursing staff alike; however, new interventions were needed to continue to facilitate progress. Additional interventions were warranted in the area of communication. The provider and nurse workgroup convened and a specific transfer plan was initiated to ensure the nurses had all questions answered while the surgeon is still present.

Conclusion: In conclusion, this project will conclude in December 2012. The outcome metrics will be collected through a postsurvey of nursing and physician staff, patient satisfaction surveys, patient safety reports, and length of ICU and hospital stay. Midpoint assessment revealed only positive results.

Nursing Implications: The interventions implemented in this project may enhance the clinical knowledge of the nursing staff and the communication with the cardiothoracic team. Additionally, the increased confidence providers have in nursing care may lead to decisions to decrease the length of stay in the ICU.

The Clinical Nurse Specialist's Role in Reducing Inappropriate Urinary Catheter Utilization

Niederhauser TM, Tocco S, Orlando Health, Florida

Purpose: To reduce inappropriate urinary catheter (IUC) utilization as a key process measure in decreasing the incidence of catheter-associated urinary tract infection (CAUTI).

Significance: Catheter-associated urinary tract infection is the most prevalent hospital-acquired infection. Each day that a urinary catheter is in place, the incidence of bacteruria increases by 5%. CAUTI can progress to bacteremia, sepsis, and even death. Literature suggests that IUC utilization is the leading contributor to CAUTI. It is estimated that up to 50% of urinary catheters in hospitalized patients have no valid indication for placement. Healthcare providers are often unaware of the presence of IUC which can lead to unnecessary urinary catheter days. The Center for Disease Control and Prevention (CDC) estimates that 17 to 69% of CAUTI can be prevented with the reduction of IUC utilization and appropriate infection control measures.

Background/Rationale: At a tertiary care level I trauma hospital, there is a known prevalence of IUC utilization. The CDC recommends routine evaluation of urinary catheter necessity as a key process measure in the reduction of CAUTI.

Approach: The CNS formed an interdisciplinary weekly rounding team composed of an infectious disease physician, infection preventionist, nursing leadership, and wound ostomy continence nurse. Inpatient units with high urinary catheter utilization were selected for the pilot. During rounds, the team collaborated with the patient/family, nurse, and attending physician to assess the appropriateness of each urinary catheter. The CDC criteria for urinary catheter utilization served as a guide for decision making but patient-specific risks and benefits for continued catheter utilization were also applied to challenging cases. Barriers for urinary catheter removal were also identified. Data on IUC incidence was collected and analyzed during the pilot period.

Outcomes: The average urinary catheter utilization on the pilot units was 22.71%. More than one-third (38.31%) of these urinary catheters were deemed inappropriate. The team was successful in removing more than two-thirds (68.01%) of the inappropriate urinary catheters. Data collection has continued since the pilot and will be updated at the time of the conference.

Conclusions: Clinical nurse specialist-led rounds were effective in reducing IUC utilization.

Implications: Ongoing CNS leadership is needed to overcome barriers to urinary catheter removal including: toileting challenges with morbidly obese patients, patient/family refusal, attending physician refusal, monitoring of intake and output in the debilitated female patient, management of incontinence, increase in nursing workload, and awareness of morbidity associated with urinary catheter utilization.

The Clinical Nurse Specialist's Impact on Cultural Transformation

Powers J, St Vincent Hospital, Indianapolis, Indiana

Significance: Cultural transformation may be required in some institutions to achieve advanced nursing practice, this can be very difficult to achieve and can take many years. However, it is well known that a culture of collaboration and advanced nursing practice directly affects quality patient outcomes. A safe, highly reliable organization where best patient outcomes are achieved is essential for hospitals to achieve during this turbulent time of healthcare reform. The use of advanced practice nurses is essential to achieve the best outcomes. The clinical nurse specialist role is focused on improving patient outcomes through evidence-based practice, research and empowerment of nurses at the bedside. The introduction of the clinical nurse specialist (CNS) role can have significant impact on cultural transformation at any institution.

Design: Our 800-bed hospital had historically been a paternalistic environment. Nurses were not actively involved in decision making unless in an administrative capacity. There was no evidence-based practice or nursing research and very little focus on professional development among the nursing staff.

Description of Methods: The implementation of the clinical nurse specialist role was the first step towards cultural transformation. Key initiatives were implemented and driven by CNSs to empower nurses at the bedside including: (1) development of an evidence-based practice program; (2) focus on nursing research and mentoring bedside clinicians in the practice of research; (3) development of a nursing research council; (4) intense focus on maintaining clinical visibility and interaction with nurses; (5) development of a clinical products evaluation team evaluation; (6) development of a protocol committee; (7) CNSs participate in shared governance councils; (8) implementation of specialty certification review courses.

Results: Current environment 5 years later is one in which nurses have an active voice in decisions related to patient care and care delivery processes. Nurses are empowered to make clinical decisions and maintain a collaborative relationship with physicians. We have conducted over 60 research studies with many of these having bedside nurses as the principal or coinvestigator.

Conclusion: Clinical nurse specialists (CNSs) are a key element when improving care and transforming a culture. Key factors in the success of the CNS team will be discussed in this presentation. This presentation summarizes the key strategies and initiatives that are imperative to achieve cultural transformation and the subsequent achievement of magnet designation.

Implications: The clinical nurse specialist plays a pivotal role in cultural transformation. This Advanced practice role is critical to change implementation and advancing nursing practice which leads to this cultural transformation. It is through the direct nurse mentoring and support that many key initiatives can be successfully implemented and achieved. Through evidence-based practice and research implementation, optimal patient outcomes can be achieved.

Clinical Nurse Specialists Smoothing the Transition From Hospital to Skilled Nursing Facility

McKenna Moon M, Gode A, Allina Health, Minneapolis, Minnesota

Purpose: Create an innovative CNS practice to address readmissions of high-risk hospitalized patients to an urban hospital after discharge to a skilled nursing facility (SNF).

Significance: Today hospital readmission rates are used to measure quality of care and formulate reimbursement. Poorly executed care transitions between hospital discharge and SNF have been linked to increased readmission rates, rising costs, and poor outcomes.

Background: Internal data analysis at a 649-bed urban hospital revealed that SNF readmission rates were twice as high as readmission rates from the home setting (11% compared with 4% at 30 days). In addition, SNF readmissions were highest in the first 14 days of admission to a SNF, peaking at 2-3 days after hospital discharge. No standardized process exists to determine discharge readiness in this population, or to facilitate a seamless transition from hospitals to SNFs.

Methods: An interprofessional Rapid Process Improvement Workshop (RPIW) was conducted in partnership between the hospital and one of its high use SNFs to analyze the current process of transitioning patients from hospital to SNF, and to develop a CNS-driven transitional care management program. A 90-day pilot began with the goals of improving the discharge transition process, through the use of hospital-based transition CNSs unique skill set, modern technology, and communication across organizations. All patients discharging to the partnering SNF were comprehensively assessed by a CNS prior to discharge from the hospital for clinical stability and discharge readiness. The CNS played a key role in addressing barriers to discharge, providing recommendations for an individualized plan of care at the SNF, and assuring discharge orders were clear and complete. The CNS was available for questions and clarification of discharged patients' needs for 72 hours after discharge from the hospital.

Outcomes: Metrics were defined, and baseline data were obtained prior to the start of the 90-day pilot. Outcome data are currently being obtained, and will be available after October 1, 2012. The metrics being measured include readmission rates (14- and 30-day), length of stay, patient/family experience, and staff/provider experience. The overall goal of this pilot is to reduce 14-day readmission rates by 50%.

Conclusions: In the absence of a complete data analysis, subjective reports have suggested that CNS involvement in the transition process has been instrumental in satisfying SNF regulatory requirements and improving the general clarity of orders received by the accepting facility. In addition, this innovative approach has promoted joint ownership of the patient after discharge from the hospital.

Implications: Clinical nurse specialists bring a unique perspective and skill set to patients and families transitioning across healthcare settings. This innovative approach highlights how CNSs utilize the roles of expert clinician, consultant, and change agent to influence healthcare quality and outcomes.

Clinical Nurse Specialists Team Up for Dramatic Improvement in Patient Perceptions of Pain Management in a Small Community Hospital

Lancaster S, IU Health West Hospital, Avon, Indiana; Brown S, Rehabilitation Hospital of Indiana, Indianapolis

Purpose/Significance: Clinical nurse specialists work with nurses and other disciplines to improve patient outcomes and to effect system-wide changes to improve programs of care. Two CNSs led an effort at a small community hospital to bring improved pain management to patients in our care, utilizing the 3 spheres of influence of the traditional CNS role (NACNS, 2004). Patient satisfaction with pain management scores improved from the 12th percentile in 2010 to the 92nd percentile in 2011 and are now sustaining at the 99th percentile in 2012, as measured by the NCR Picker, Value Based Purchasing metric.

Design/Methods: A replication of the Pain Resource Nurse program was rolled out by the lead CNS (a doctoral student at this time) in spring of 2010, including pharmacists and rehabilitation therapists, along with a group of registered nurses. Statistically significant improvements in Knowledge and Attitudes about Pain Management were achieved with this core group, both at the immediate posteducational measurement and at the 6 month follow-up period.

Methods: The pain resource nurse (and colleagues) team has continued to meet monthly under the leadership of the second CNS and works collaboratively to improve pain management in our facility. The pain team has spearheaded physician education on addiction and multimodal pain management, 2 pain fairs, a pain art contest, and monthly unit Pain Tidbits for staff education. Along the way, around the clock dosing for acute pain and end of life and palliative pain management were special areas of focus with educational flyers promoting evidence-based practice in these important areas. The CNS role of direct patient consulting, and encouraging and coaching of direct caregivers has resulted in increased staff ability and willingness to advocate for good pain management. Staff who have specialized skills guided imagery and other nonpharmacological pain management approaches were coached to provide peer education, which has been highly effective. Under the clinical and professional leadership of the CNS a Pharmacy Pain Consult service was advocated for and added in mid-2011. The CFO and CEO gained a better understanding as to the impact and necessity of this important addition to our collaborative pain management program through the persuasive efforts of the CNS. When the 99th percentile was achieved, concerns were raised about patient safety in the area of pain management. In response, the CNS led an effort to review Narcan use and pain medication safety through a retrospective review of all patients receiving Narcan. This CNS worked collaboratively with the hospitalist team to achieve optimum patient outcomes and safe practice.

Outcomes/Conclusions: Pain management was greatly enhanced at this small community hospital by the collaboration of 2 seasoned CNSs with a passion for improving this specific patient outcome.

Clinical Nurse Specialist Influencing Practice Through a Staff Nurse Peer Review Council

Paul D, Somerset Medical Center, Somerville, New Jersey

Purpose: Describe how the CNS can drive clinical issue analysis to improve patient outcomes.

Significance: Peer review is a necessary process to maintain control over practice. The purpose is to evaluate the quality and quantity of nursing care and to identify if there is consistency of established standards of care. The CNS as the facilitator for a council of staff nurses is in a role that can influence nursing practice and patient outcomes through the ability to lead, teach and mentor effectively.

Design (Background/Rationale): At a 350-bed hospital with a shared governance model, a peer review council (PRC) was developed using the ANA peer review principals. All RNs on the council were educated about the peer review process, chart navigation, confidentiality and providing feedback by the CNS.

Description of Methods: The PRC participates in an examination of details of a specific case or series of related cases to determine what occurred, why it may have occurred, if there was a deviation in the standard of care, trends in practice and what can be learned. The CNS identifies the cases to be reviewed prior to the monthly meeting, establishes a framework for the review and provides a safe environment for the staff to effectively evaluate the actions of peers in a nonthreatening manner. The CNS works with the staff to generate a report from the committee, forwards it to the individual or group requesting the review and provides a biannual presentation of their findings and recommendations to the Performance Improvement Council.

Finding/Outcomes: A nonpunitive review of the standard of care and nursing practice allows for identification of achievements, trends, and/or barriers which can drive practice change, policy change or identify a learning need. A highlight of review outcomes include: identifying a variance in the way nurses from shift to shift evaluate fall risk, a need for policy on use of reversal agents for sedation in the mechanically ventilated patient, development of a more formal protocol once a patient is identified as a low risk for suicide, identification of a variation in dispensing of heparin infusions from the pharmacy to name a few.

Conclusions/Interpretations: The CNS is in a unique position to mentor, support and guide staff, teaching them to be able to evaluate practice and provide objective, honest feedback. In addition staff has the opportunity to see the fruit of their labor through peer validation, change in practice, changes in policy or education sessions.

Implications: Providing mentorship and a safe environment for the staff nurse to effectively evaluate peers incorporate evidence in to practice, and to stimulate reflective practice will promote accountability and allow the staff autonomy in their practice.

Clinical Nurse Specialist Innovation: Development of a Portfolio and Interview Process to Validate Transition of New Graduate RNs Into Practice

Elgin K, Rea K, University of Virginia Health System, Charlottesville, Virginia

Purpose: The implementation of a structured process for validation of new graduate RN practice through a peer reviewed mechanism will support professional growth and development for novice clinicians within a complex acute care system. Additionally, it will provide a means for advancing peer review competencies of experienced RNs. The CNS positively impacts within the nurse sphere of influence by creating the infrastructure, coaching and guiding and evaluating the process outcomes.

Significance: Organizational guidelines and process for advancement of new graduate RN clinicians on an established career ladder do not define a panel interview process as part of validation of candidate practice. There is professional growth and development that occurs through the process of peer review and formal interview for both the candidate and peer panelists.

Design (Background/Rationale): A formalized panel review process, involving input from RN peers, supports the evolution of new graduates through the initial phases along a development continuum. Supplementing an organizational advancement process bolsters the validity of new graduate advancement and contributes to the professional practice environment.

Description of Methods: A review of new graduate advancement materials occurs by an appointed panel of peers 12 months poststart date. Materials include curriculum vitae, self-evaluation, peer reviews, and a clinical exemplar. These peers include 2 experienced nurse colleagues and a clinical nurse specialist. The candidate meets with this panel to elaborate upon submitted materials and provide clarification as deemed necessary. The panel makes a recommendation to the manager regarding advancement of the candidate based on established clinical and professional behaviors. The CNS quantifies the outcomes of the model through participant feedback, time invested, RN satisfaction, and new graduate turnover.

Findings: New graduate nurses experienced professional validation through the creation and critique of their portfolio. The experience of being interviewed by peers and clinical leaders provided positive feedback and an opportunity to articulate goals and set an expectation of future professionalism.

Conclusions: All participants believed that the creation of their portfolio and preparation for interview were positive experiences. The process of preparation was viewed differently by individuals and all recommended it to others. Educational preparation influenced how prepared new graduates felt for the process. Peer panel reviewers found the process supported their own professional development. The interview became a vehicle for positive reinforcement, strength and growth area identification and an opportunity to discuss practice and team dynamics.

Implications: Nurses benefit from a structured process for clinical validation. The CNS engages and guides their transition from novice to competent clinicians. The CNS coaches the individual and their peers through the validation process which fosters a climate of professionalism. This professional development innovation provides return on investment for all involved.

Clinical Nurse Specialist Implementation of a Transradial Cardiac Catheterization Program Through Interdisciplinary and Interdepartmental Collaboration

Faas A, St Mary's Hospital, Madison, Wisconsin

Significance: The femoral artery site for cardiac cauterizations frequently requires bed rest for several hours and the use of hemostasis devices to provide during arterial and venous line removal. Patients can experience pain and discomfort during the removal process. The risk of hematoma formation and retroperitoneal bleeds are present. Use of the radial artery as the access sites reduces the length of time for bed rest, decreases pain and discomfort, and significantly reduces the risk of hematoma formation.

Design: St Mary's Hospital Cardiac Services line rarely performed transradial cardiac catheterizations. Two of the interventionalists had performed radial artery catheterizations in the past. A program was designed and a process developed to implement a transradial cardiac catheterization program.

Description of Methods: Interdisciplinary collaboration with physicians identified an aggressive timeline. The cardiac services clinical nurse specialist (CNS) identified key catheterization laboratory and nursing unit team members who would be caring for the patient population precatheterization and postcatheterization. The CNS led the team, which identified required education elements for the new plan of care, procedures, equipment, order sets and documentation. To facilitate physicians' implementation of cases by the transradial route, the first 2 weeks of the timeline were devoted to education of the catheterization laboratory staff and the cardiac procedure unit staff. The cardiac procedure unit monitored the first 20 patients until the hemostasis device was removed. The surgical services CNS, cardiopulmonary CNS, and the cardiac services CNS devoted a second 2-week period to staff education in the surgical procedure center and intermediate cardiac care unit. After the education was complete, patients returned to the unit from which they originated for postprocedure monitoring and hemostasis device removal.

Outcomes: The transradial program launched on the designated date. The cardiac catheterization laboratory and cardiac procedure unit had been educated about the new processes and procedures. The first twenty patients were managed according to the plan and no adverse outcomes present. The transition of postcare monitoring to the surgical procedure center and the intermediate care unit was a smooth transition. Clinical nurse specialists provided one-on-one support for the Registered Nurse caring for the patient after transradial catheterization as needed. To date, no major complications have occurred.

Conclusion: Implementing a new program in a short time frame is possible with an interdisciplinary and interdepartmental approach. The short time frame did not allow for the build of the new order sets in the electronic health record, which resulted in confusion for the Registered Nurse caring for the patient preprocedure and postprocedure. Same-day discharge for patients who had undergone an intervention is not usual practice at this institution. The first transradial patient became a same-day discharge patient and the implementation plan had not addressed the process flows required for this new process.

Implications: Transradial cardiac catheterizations provide for increased patient satisfaction. Implementing a transradial program in a short time frame can be accomplished; expect on-going process changes as the program further develops.

Clinical Nurse Specialist Led Fall Program: Improving Performance Through Environment Sweeps

David CM, Shaffer B, Zellars R, VA Pittsburgh Healthcare System, Pennsylvania

Purpose: The aim of this evidence-based practice (EBP) project was to decrease patient falls and injuries by improving our facility's adherence to fall program guidelines and applying evidence-based practices that aid in fall/injury reduction.

Significance: Falls represent the most common adverse event within long-term care (LTC) facilities with 3 of 4 residents falling each year. As Medicare no longer reimburses for injurious falls that occur during a residence's stay, falls represent a significant loss in revenue. With the recognition of this problem and need to adhere to The Joint Commission's safety goal "Reduce the Risk of Falls," LTC facilities establish fall programs to guide practice and aid in the reduction of falls and injury. Program effectiveness is often limited due to staff and resident inconsistent adherence with fall program guidelines.

Background: The project influenced the organization, nurses, and residents' sphere of influence with a multidimensional intervention that ensured a safe environment, increased residents' awareness of risk, and increased staff consciousness of risk. This was accomplished by providing an avenue for continuous staff and patient education. It also created an avenue for all stakeholders to analysis issues and create plans for improvement.

Methods: The project combined several EBP concepts into 1 monthly intervention which included nonpunitive CNS and administration guided staff environment monitors, resident education using the "teach back" method, staff education, and postintervention huddles to discuss findings and corrective actions. Quarterly unit staff briefings were held to share outcomes, success, and fall event/program compliance trends. Unit staff were asked why these trends are noted and what actions can feasibly be implemented to ensure continued improvement.

Outcomes: Since the implementation, our fall rates per 1000 bed-days of care declined from 5.94 (2011 accumulative rate) to 4.75 (2012 accumulative rate). Major injury rates declines from 0.08 (2011 accumulative rate) to 0.04 (2012 accumulative rate) with a minimal estimated healthcare cost savings of $55 224.

Conclusions: Clinical nurse specialist- and administration-guided environmental monitoring that includes staff, resident education per the "teach back" method, and staff participation in creation of performance improvement plans may aid in decreasing falls, injurious falls, and costs of care related to falls by helping to ensure adherence to fall prevention guidelines and plans for improvement.

Implications: By continuously involving all spheres in fall program performance evaluation and improvement plans, sustained positive outcomes are more likely as all stakeholders are involved in the process change and the feasibility of actions.

Clinical Nurse Specialist-Led Practice Improvements in the Nursing Management of Autonomic Dysreflexia

Rovito DL, Louis Stokes VA Medical Center, Cleveland, Ohio

Significance: In 2012, the CNS assigned to the spinal cord injury (SCI) service of a large medical center designed an autonomic dysreflexia (AD) nursing template with the assistance of an electronic medical record clinical applications coordinator. The CNS trained all licensed SCI nursing staff on the inpatient SCI unit in its use and it became mandatory that AD Work Sheet data collected at bedside during AD was to be documented in the template after each episode. After the template was consistently used by staff, the CNS created an additional summary report that could locate completed AD templates in the electronic medical record for evaluation by the CNS.

Background: Autonomic dysreflexia is a potentially life-threatening condition that is characterized by sudden, severe increases in blood pressure. It occurs in patients with spinal cord injury (SCI) at or above the T6 level of the spine. Resolving an episode of AD requires timely recognition and rapid treatment. Symptoms and treatment will vary among patients and with each episode of AD, thus interventions to resolution can be complex. Nurses who work with SCI patients are often the first healthcare providers to recognize and initiate treatment when AD occurs. AD protocols are typically based on the recommended clinical practice guidelines of the Consortium for Spinal Cord Medicine and are usually articulated in institutional policies and procedures. The purpose of this CNS-led performance improvement initiative was to use consortium and local guidelines to evaluate AD documentation, to identify areas for improvement in the nursing management of AD, and then to design interventions within the nursing sphere that would drive these improvements.

Methods: Baseline data were collected between January and June 2012. There were 67 AD episodes documented in the electronic report as occurring on the inpatient SCI unit. The CNS used a simple grid to assess documentation for deviations from 8 key elements based on Consortium guidelines and local policy.

Findings: The CNS identified 2 specific items as needing improvement. Use of nitroglycerine ointment to lower blood pressure was suboptimal in 52% of the episodes, and in 96% of the episodes, there was no documentation of blood pressures that Consortium guidelines recommend to be taken for 2 hours once the AD episode ends.

Interpretation: The CNS recognized 3 interventions in the nursing sphere that could impact on improving performance in the targeted areas. First, the documentation template was altered to clearly identify the end of episode BP and an area was added for entering the follow up BPs for 2 hours. Second, redesign of the AD work sheet by the CNS provided more cueing to guide decisions related to the use of nitroglycerine ointment as well as the documentation of the final BPs. Finally, all licensed nursing staff were reeducated about AD and pharmacological management by the CNS. When daily documentation reviews revealed missed or delayed opportunities to use nitroglycerine ointment, the CNS provided one-on-one consultation with staff nurses.

Implications: Data postintervention are in the process of being collected. Data collection will end on January 1, 2013, and the impact of the CNS's targeted interventions to improve compliance with clinical practice guidelines will be determined.

The Clinical Nurse Specialist Role in the Development of a Neurosurgical Service Line at a Level 3 Trauma Center

Dewey, A, Bayhealth Medical Center, Dover, Delaware

Purpose: This session will describe the role of the clinical nurse specialist (CNS) in developing a neurosurgical service line at a level 3 trauma center serving a rural community. The CNS influence in 3 spheres, systems, patients/families, and nursing practice, assisted the multidisciplinary team to design a successful neurosurgical service line.

Significance: The CNS expertise was vital in the development phase of the new neurosurgical service line through their ability to utilize and integrate evidence-based practice, systems thinking, along with proficiency in patients/family care and nursing practice.

Background: The healthcare organization had not performed neurosurgical intervention for over ten years. Patients who had presented to the organization with a neurosurgical problem were transferred to a tertiary care center over fifty miles away for treatment.

Methods: Preliminary planning for the neurosurgical service line began as a multidisciplinary collaboration mentored by the chief neurosurgeon. The CNS assisted in designing new processes for neurosurgical patients utilizing the 3 spheres of influence. In the systems sphere, the neurosurgical patient experience was mapped out whether the patient entered through the emergency department or as an elective neurosurgical patient. The care processes were also developed from the acute inpatient hospitalization, discharge, rehabilitation and follow-up outpatient care. The CNS designed a variety of educational opportunities for the multidisciplinary team to gain insight and experience in neurosurgical care, thus exerting influence in the patient/family and nursing practice spheres. These included visitation and collegial relationships with other healthcare organizations, online education learning, equipment demonstrations, patient simulations, tracer methodology, and bedside mentorship.

Outcomes: A diverse neurosurgical patient population of over 600 received state of the art neurosurgical care over the past year near their home and support systems. The population included patients requiring neurosurgical care for mass removal, arterial-venous malformation, traumatic and nontraumatic intracranial bleeding, aneurysm clipping, and severe traumatic brain injury (TBI). Cost-effective, quality outcomes for the neurosurgical patient were achieved with the assistance of the CNS. Case exemplars include a 21-year-old man with severe TBI who is now residing at home as well as a 55-year-old woman who had severe vasospasm after a subarachnoid hemorrhage and aneurysm clipping that is now back to enjoying her family.

Conclusions: The role of the CNS in developing a new service line such as neurosurgery cannot be overstated. The effect of the CNS influence through 3 spheres, provides valuable expertise in transforming care in a level 3 trauma center in a rural community hospital.

Implications: Healthcare organizations should include the CNS as a key stakeholder when developing new service lines. The CNS practice within the 3 spheres of influence provides a variety of perspectives and innovative solutions to achieve successful outcomes.

Code Blue for First Responders Program for Lower-Acuity Settings

Rocha ED, Palomar Health, San Diego, California

Purpose: Lower-acuity settings such as behavioral health, acute rehabilitation, and labor/delivery/postpartum units typically lack the resources to respond to rapidly deteriorating patients. The purpose of this evidence-based practice project was to implement a plan for a coordinated response to code blue arrests.

Significance: Cardiac arrest is a significant cause of morbidity and mortality in the hospitalized patient. Successful resuscitation depends on early recognition and prompt intervention by knowledgeable providers. In settings where code blue arrests are infrequent, patient survival has been positively impacted by the presence of a trained, coordinated, consistent response team.

Background: With the scheduled opening of a new acute care medical facility in this suburban setting, medical/surgical, intermediate and intensive care units would be relocated leaving the remaining lower-acuity levels of care in the older facility without these resources. The loss of the code blue response team, composed of staff from these units, was a concern of both leadership and staff. A plan to address concerns, including transportation to the new facility and higher acuity level of care, was requested by leadership.

Project Description: Following leadership meetings, a group of stakeholders met to assess needs and determine the composition of a coordinated code blue response. A code blue algorithm of personnel, roles, and responsibilities was formulated. A 3-hour Code Blue for First Responders course was developed by CNSs and included the presentation of the code blue algorithm, 2 hours of hands-on skills in recognition and initiation of code blues, use of the AED, and orientation to and utilization of the crash cart to include scribing. Classes were open to any staff remaining at the older facility and were taught by CNSs from across the system. Nine classes were offered over a 2-month period prior to the opening of the new hospital.

Outcomes: A total of 135 staff attended the classes and a written evaluation was received from each participant. Eighty-three percent (83%) gave this program a "5" or "excellent" and 97% gave the instructors a "5" using a Likert scale of 1-5. Appreciation for the opportunity to network and share concerns across units was also expressed verbally to instructors in all 9 classes. Readiness testing was performed using the Code Blue for First Responders algorithm and debriefing sessions were held at both the unit and system-wide levels. Thirteen staff members attended and 100% verbalized relief at having a process in place and stated they felt better prepared to respond to code blue situations. One hundred percent (100%) verbalized the need to continue code blue drills.

Interpretation/Conclusion: The healthcare system now has a coordinated response to code blues in low acuity settings.

Implications for Practice: The Code Blue for First Responders class will continue to be offered on a routine basis. Ongoing unit-based and hospital-wide drills will be managed by the perinatal CNS and emergency department educator.

A Collaborative Team Caring for a Young Pregnant Cancer Patient

de Villers AA, Orlando Health, Clermont, Florida

Significance: Providing care to a patient who is pregnant and has a new diagnosis of Leukemia is a special complex challenge to both the oncology nurses as well as the obstetrical nurses. Nurses who work in these specialized areas possess specialized knowledge and skills unique to their population. The adult oncology clinical nurse specialist (CNS) can work with these specialized areas to facilitate collaboration that will provide support in the form of education, clinical expertise, and navigation through the healthcare system for both nurses and the patient.

Design: Cancer occurs in 1 per 1000 to 2000 pregnancies per year. The most common cancers that occur in pregnancy are cervical cancer, breast cancer, lymphoma, and melanoma. A diagnosis of Leukemia during pregnancy is very rare. The purpose of this collaboration was to provide a "bridge" for the care of the pregnant cancer patient. Collaboration of care between 2 specialized nursing fields, oncology and obstetrics, will result in safe and effective patient outcomes.

Description of Methods: The adult oncology CNS collaborated with the Winnie Palmer Hospital (WPH) women's services (high-risk obstetrics) nursing leadership to provide care for a high-risk pregnant oncology patient. The team also developed a plan of care for the pregnant cancer patient and strategies to educate the nursing staff regarding the appropriate nursing care. The oncology nursing team provided patient education and administered chemotherapy in the high-risk obstetrics unit. The adult oncology CNS assessed the patient's status daily as well as providing support and education to the high-risk obstetrics nursing staff regarding anticipated adverse effects of neutropenia, anemia, thrombocytopenia, nausea and vomiting, and others.

Findings and Outcomes: The patient was able to receive appropriate fetal surveillance, and received 2 cycles of chemotherapy during the course of hospitalization. The baby was delivered at 30 weeks' gestation via cesarean delivery. The mother was discharged and readmitted to the oncology unit. The neonatal intensive care unit's (NICU's) leadership and the adult oncology CNS arranged to have a Web camera brought to the mother's hospital room allowing the mother see her baby at anytime during her hospitalization which facilitated "bonding" between mother and baby.

Conclusions/Interpretations: Collaboration between the nurses and physicians allowed the patient to visit the WPH NICU in between doses of chemotherapy. The patient and nursing staff expressed satisfaction with the delivery of the plan of care and outcomes. Currently, the patient continues to receive treatment for leukemia and the baby was recently released from the WPH NICU.

Implications: Collaboration between nursing specialties for special complex patient populations is necessary for delivery of safe and appropriate nursing care resulting in satisfactory patient outcomes. The adult oncology CNS provided leadership for this type of clinical collaboration across specialties within a healthcare system.

A Comparative Study of 2 Methods for Turning and Positioning and the Effect on Pressure Ulcer Development

Powers J, St Vincent Hospital, Indianapolis, Indiana

Significance: Pressure ulcers occur in 3 million people in the United States. Patients must be effectively turned in order to relieve pressure that can result in skin breakdown. Multiple studies have demonstrated that appropriate turning does not get accomplished for patients as needed.

Design: The purpose of this study was to compare 2 methods for turning and positioning ICU patients and evaluate the effect on incidence of hospital-acquired pressure ulcers. Secondary aims for this study were to measure degree of turn and nurse satisfaction with turning methods.

Methods: A blocked design with a convenience sample of 60 patients was used for this study. The comparison study was completed between standard of care (SOC) involving traditional turning using pillows and a new turning and positioning device (TAP).

Findings: There was a statistically significant difference in the number of pressure ulcers between groups (6 vs 1), P = .042. There were no statistically significant differences between groups for Mobility score, Braden score, gender, age, or BMI. These factors were not identified as predictors for the development of hospital-acquired pressure ulcers. There was a significant difference in the degree of turn between groups. Patients in the SOC group required more resources for repositioning; 88% of nurses preferred the TAP system over SOC.

Conclusion: Standard of care for turning and positioning patients may be ineffective in preventing the development of pressure ulcers when compared with TAP. Standard of care also does not achieve the desired 30 degree turn and does not maintain the initial turn achieved.

Implications: Effective turning and positioning are essential to prevention of hospital-acquired pressure ulcers. Nurses are instrumental in preventing patient complications, especially hospital-acquired conditions. Through adoption of an efficient method for positioning patients, hospital-acquired pressure ulcers can be prevented.

A Comparison of 3 Burn Resuscitation Formulas: The Clinical Nurse Specialist Role

Robbins JR, US Army Institute of Surgical Research; Allen DA and Mann-Salinas E, USAISR; Serio-Melvin ML, Fort Sam Houston, Texas

Purpose: To compare and contrast 3 burn resuscitation formulas: Rule of 10, Modified Brooke, and Parkland formulas through application to a clinical case in a combat zone in Iraq. Implications within the clinical nurse specialist (CNS) spheres of influence will be discussed. With several formulas to choose from, the CNS will provide a vital role in the initiation and guidance of burn resuscitation.

Significance: During a mass casualty incident it is certain that a percentage of casualties will sustain some type of burn injury. The team is frequently challenged to identify the best mathematical formula to calculate fluids indicated in burn resuscitation while working under pressure in a crisis situation. The burn casualty often has other associated injuries that also require focused medication attention in addition to initiation of resuscitation.

Background: In the combat setting the CNS is often the only Advanced Practice Nurse on a medical team and thus is in the ideal role to guide the team in calculating fluid replacement. The Rule of 10 is a simplified method to initiate fluid resuscitation, based simply on burn size multiplied by a factor of 10 to initiate the starting infusion rate.

Description: Improvised explosive devices (IEDs) are a common threat faced by US Service Members in Iraq and Afghanistan. In fact, more Soldiers, Sailors, Airmen and Marines have died as a result of IEDs in the Iraq and Afghanistan wars than all other combat-related causes combined. During Operation Iraqi Freedom, many Soldiers would go into places where insurgents would hide IEDs. A 28-year-old 70-kg man infantry soldier was out on patrol with his squad at night when he came across something that looked peculiar. After investigating the situation, he tripped a wire and sustained 50% total body surface area (TBSA) burns after an IED blast.

Outcome: When applied to the 70 kg patient with 50% TBSA burns, the Rule of 10 closely approximates initial fluid rate of 500 mL/h that could be derived using Modified Brooke formula (438 mL/h) and provides a safe and efficient tool for rapid estimation. When compared with the Parkland formula (875 mL/h) it has a considerably lower initial fluid rate. For all formulas, titration of fluid to achieve target urinary output of 30 to 50 mL/h is expected treatment.

Interpretation/Conclusion: The CNS working with the healthcare team caring for burn patients at a non-burn center can meet American Burn Association guidelines of care and competently guide care for the patient with burns by using the Rule of 10 to begin initial fluid resuscitation.

Implication for Practice: The CNS can bridge the spheres of influence to help improve burn patients' outcomes through expert consultation, care coordination, monitoring quality indicators, and expert communication between the healthcare team and family. The CNS working at the system level can facilitate use of the Rule of 10 to improve clinicians' confidence with burn resuscitation and improve patient outcomes by decreasing risk of fluid overload.

Competence and Responsiveness in Mothers of Late Preterm Infants Compared With Mothers of Term Infants

Baker BJ, Virginia Commonwealth University Health System, Mechanicsville

Purpose: To examine maternal competence in mothers of late preterm infants, compared with mothers of term infants. The conceptual framework includes factors associated with maternal competence and responsiveness including support, self-esteem, well-being, stress, and mood. In addition infant factors of temperament and vulnerability are included.

Significance: Late preterm infants are a newly identified group of preterm infants who behave differently than term infants and present mothers with unique challenges.

Design: A nonexperimental repeated-measures design examined maternal competence and responsiveness in 2 groups of postpartum mothers. Data collection occurred during the postpartum hospitalization and again at 6 weeks postpartum. Participants were compensated with gift cards for completing and returning surveys.

Methods: Nonexperimental cross-sectional, repeated-measures design to compare maternal competence in 2 groups of postpartum mothers. Descriptive and bivariant analysis was conducted to illustrate factors predictive of maternal competence and responsiveness.

Findings: Over a 6-month period, 109 mother/infant dyads were recruited. Seventy-seven term and 32 LPI mothers completed the first survey during the postpartum hospitalization. Seventy-one mothers (52 term and 19 LPI) completed data collection at 6 weeks postpartum. Scores increased for both term and LPI mothers from postpartum to 6 weeks postpartum on scales measuring competence and responsiveness. There was no statistically significant difference between groups or between measurement times on measures of competence or responsiveness. Factors predictive of maternal competence at 6 weeks in term mothers included satisfaction with life and in LPI mothers postpartum support. Factors most predictive of responsiveness in term mothers at 6 weeks included self-esteem and for LPI mother's self-esteem, stress, and infant temperament.

Conclusions: No significant difference was appreciated between groups or within groups on scores of competence or responsiveness. However factors contributing to the development of competence and responsiveness differed between groups.

Implications: Identification of factors that support development of maternal competence and responsiveness in LPI mothers allows care providers the opportunity to better prepare mothers and families for discharge. Understanding the experience of LPI mothers further supports development of the maternal role and ultimately growth and development of the newborn and child.

Comprehensive Oral Care to Prevent Non-Ventilator-Associated Hospital-Acquired Pneumonia

Quinn B, Sutter Medical Center; Baker D, California State University School of Nursing; Parise C, Sutter Institute for Medical Research, Sacramento, California

Purpose: To apply evidence-based nursing interventions to prevent non-ventilator-associated hospital-acquired pneumonia.

Significance: Hospital-acquired pneumonia (HAP) is the second most common hospital-acquired infection in the United States and contributes to increased patient morbidity, mortality, extended lengths of stay, and costs of $40 000 to $150 000 per case. Although numerous studies have reported incidence and prevention of ventilator-associated pneumonia (VAP), nonventilator hospital-acquired pneumonia (NV-HAP) has been understudied. In a previous 2010 study, we identified 115 adults who were coded for NV-HAP and also met the Centers for Disease Control and Prevention definition for HAP. By extrapolating national HAP outcome data, this resulted in an estimated cost of $4.6 million, 1035 extra hospital days, and 23 lives in our institution.

Background: The Institute for Healthcare Improvement recommends specific interventions which reduce or prevent VAP. By applying appropriate evidence-based interventions for all patients at risk for HAP, we can prevent this common hospital-acquired infection. According to the Centers for Disease Control and Prevention, the combination of 3 events leads to the development of HAP: (1) having pathogens in the mouth and throat, (2) aspirated into the lungs, (3) in a patient with poor mechanisms of defense. By targeting modifiable risk factors, NV-HAP can be prevented. Based on our review of the literature, reducing the pathogens in the mouth and throat has the most potential for modification, so the decision was made to begin our prevention efforts with an oral healthcare campaign.

Description of Methods: We used a CNS-led, multidisciplinary approach using the Influencer Model to implement a comprehensive oral care program for every patient in the hospital. Team members included respiratory therapy, rehabilitation, pharmacy, nursing, administration, nutrition, central supply, physician, and health information expertise. We also developed an academic-community partnership with our local school of nursing. Based on the science in the literature and evidence-based guidelines, the CNS completed a gap analysis and made recommendations for interventions to address any shortfalls. We developed a new oral care protocol for all patients. We evaluated, standardized, and purchased new oral care tools and developed new patient education materials. We created audit tools and revised our documentation to better reflect recommended practice. We developed and taught mandatory oral care classes to all nursing assistants to help them understand the value of oral care. We started with 3 pilot units: telemetry, medical/surgical, and orthopedic, with a plan to spread hospital-wide.

Outcomes: Since April 2012, we have implemented a comprehensive oral care protocol, educated staff and families, and changed our oral care products. Oral care frequency has improved from a baseline of 27% of patients receiving oral care once each shift, to receiving oral care each shift 80% of the time. We have seen a 73% decrease in incidence of NV-HAP on the same 3 pilot units.

Conclusions: A CNS-led initiative, using a team approach, was successful in implementing a comprehensive oral care program and decreasing the incidence of NV-HAP on 3 pilot units.

Implications for Practice: A team approach with CNS leadership is an effective way to accomplish substantial improvement in the prevention of NV-HAP. The application of this model may be helpful to prevent NV-HAP at other institutions.

Computerized Documentation of Clinical Nurse Specialist Student Competencies: Making Clinical Outcome Evaluation Robust

Vollman KM, Poindexter KA, Michigan State University, Big Rapids

Purpose: To design a comprehensive computer-based outcome performance measurement system to document student clinical hours and achievement of adult gerontological CNS competencies within the 3 spheres.

Significance: Capturing the range of diverse competencies required of CNS students such as; change management, care of complex patient situations, product evaluations and integration of evidence into practice, makes outcome documentation of these skill sets extremely complex. The integration of a continuous computerized tracking system designed specifically for the role of the CNS provides an organized approach to monitor and assess student learning experiences. When the student, preceptor and clinical faculty are able to follow the progression of learning simultaneously, the ability to ensure robust evaluation can be achieved.

Background: Computer documentation of clinical hours and completion of skill sets is widely used in CRNA and NP graduate programs to capture type and frequency of skills performed by their students. The unique skill sets of the clinical nurse specialist are not well defined in the current tracking systems making them inefficient and cumbersome to implement into CNS graduate programs of study. A computerized tracking system specifically designed to capture the CNS competencies and evaluate student performance would provide an effective way to facilitate comprehensive clinical experiences.

Description: Using the data management platform of an existing computerized tracking system, a program was designed to specifically reflect the unique skill set of the CNS. This redesign provided students with an organized structured framework to document their clinical activities and associate them with specific CNS competencies under the appropriate sphere of influence. Time tracking is achieved when the student enters their clinical hours on the corresponding calendar. A unique feature of this system requires preceptors to validate student documentation of clinical activities and clock hours in collaboration with clinical faculty to ensure a comprehensive clinical experience.

Outcomes: (1) A continuous tracking system to document student progression and achievement of course and program outcomes; (2) preceptor, student, and faculty access to required clinical competencies strengthens the team's ability to design experiences tailored to student needs; (3) clinical evaluations include preceptor assessment and faculty evaluation of student performance readily available in pdf format; and (4) comprehensive CNS course, program, and student evaluation data required for individual and organizational record keeping and accreditation purposes.

Interpretations/Conclusions: This system demonstrated sophisticated integration of evaluation of student clinical performance and hours documentation between clinical faculty, site preceptors and the student at any point during the course. It leads to greater clarity of strengths and weaknesses to individualize learning plans to meet course outcomes.

Implications for CNS Education: Greater communication and structural links between student, preceptor and faculty. The student is required to connect each clinical activity performed with a specific competency and appropriate sphere of influence to foster greater understanding of the dynamics associated with the CNS role.

Conflict Management Styles of Advanced Practice Registered Nurses Enrolled in a Doctor of Nursing Program

Gilliland I, Cassells H, McNeill J, Munoz L, Nadeau J, University of the Incarnate Word, San Antonio, Texas

Significance: Safety in healthcare has been tied to collaborative teams. Conflict engagement is an essential precursor to collaboration which occurs within the context of professional relationships (Kriteck, 2011). Thus, effective collaborative teams require the ability to manage interpersonal conflict. Resilience, a more intrinsic trait, assists professionals to moderate their responses to interpersonal conflict and stress. Little is known about the conflict management styles of APRNs and even less about the styles of students in higher degree programs in nursing.

Study Purpose: To (1) describe the stress resiliency and conflict management styles of practicing APRNs enrolled in a DNP program, (2) examine the relationships of stress resiliency, conflict management styles, and selected demographic characteristics. Methodology Research design. A descriptive/correlational design examining 3 cohorts of students: a quasi-experimental approach without a control group and a hermeneutical phenomenological analysis of qualitative interviews.

Sample: Purposive sampling of students in the first 3 cohorts of a new DNP program.

Instruments: Three tools to collect quantitative data: a researcher-designed demographic inventory, the Thomas-Kilmann Conflict Mode Instrument, and the Stress Resiliency Profile. An interview schedule guided qualitative data collection. Interview questions used as probes were developed based on analysis of the baseline responses to the quantitative assessment.

Preliminary Findings: Analysis of this group (n = 11) revealed a mean age of 46 years (SD, 9.5 years; 34-59 years); the majority were female (7; 64%), with an average of 17 years nursing experience and a mean of 7 years as APRNs. Over half (6; 55%) self-identified as Hispanic or Asian. Fifty-five percent reported previous experience with interpersonal conflict in the workplace. Baseline scores indicated a high preference for the avoiding conflict management style and low preference for the collaborating conflict management style. Stress resiliency subscale scores indicated most students focused on their deficiencies and had low skill recognition scores suggesting a predisposition to stress. Analysis of qualitative data supported the quantitative finding that avoidance is the conflict management mode most frequently utilized and the older the APRN the more likely is the use of avoidance. Additionally, more years of experience make the APRN less likely to use compromise. Most conflicts occurred between the APRN and other professional colleagues and dealt with issues of role expectations. Lack of position power within the work system led APRNs to the use of avoidance. Unrealistic role expectations and feelings of being undervalued and unappreciated created stress for the APRNs.

Conclusion and Implications: Findings reinforce the importance of curricula that expose CNS students to interprofessional team experiences and provide tools to augment conflict management and stress resiliency. Findings suggest that conflict management should be included in all CNS and DNP programs to better prepare APRNs as leaders of interprofessional teams.

Core Competencies in Action: Defining Clinical Nurse Specialist Practice and Behaviors at the Point of Care

Hujcs M, Hospital of the University of Pennsylvania, Philadelphia

Purpose: This presentation will describe clinical nurse specialist (CNS) practice demonstrating the national CNS Core Competencies to promote patient safety, quality patient care and clinical outcomes for a neurocritical care population. Successful strategies indicative of specific components of the core competencies as measurable behaviors that define CNS practice will be discussed.

Significance: While defined core competencies exist, how these specific competencies are demonstrated or evaluated in practice has not been standardized. Establishing a methodology for examining CNS practice related to core competencies facilitates defining the unique responsibilities and contributions of the CNS as an advanced practice nurse. Incorporating the core competencies and behaviors into a peer review process further validates CNS practice.

Background: Clinical nurse specialists are essential in integrating evidence-based practices that support patient care, outcomes, appropriate resource utilization, and safety. Leading interdisciplinary teams, promoting collaboration, mentoring nurses and health professionals and sustaining cost-effective quality patient care are repeated themes within the core competencies. Demonstrating these behaviors validate core competencies at the point of care.

Description: In an urban quaternary academic medical center, CNSs utilize core competency descriptors as role accountabilities and evaluation in a peer review process. In an annual evaluation, each CNS participates in peer review based on these accountabilities. Additionally, a voluntary promotional process incorporates more detailed peer review of specific projects and outcomes. Both processes highlight the unique nature of CNS practice.

Outcome: Utilizing a model of care that promotes goal directed therapy for neurocritical care patients, CNS-led initiatives have resulted in 8 innovative, collaborative protocols defining standards of care; CNS-facilitated initiatives have resulted in standardization of 3 unique nursing practice protocols at this organization. As a result, improved population based patient outcomes have been demonstrated in glycemic control, patient temperature control, osmotherapy, cerebral salt wasting, early enteral nutrition, sedation utilization, early mobility, incontinence management, chest physiotherapy and end of life guidelines for terminal withdrawal of treatment. Sustainable change has been achieved affecting a new standard of care these patients receive. These specific examples incorporate components of the core competencies including systems leadership, collaboration, coaching, and research.

Conclusions/Interpretations: Effective strategies designed to validate CNS core competencies and behaviors facilitate successful utilization of the CNS in various clinical settings. The CNS role is recognized as a necessary link to patient, nurse, and organizational outcomes. Clinical nurse specialist practice is unique as an advanced practice nurse provider; consistent methodology, description and evaluation of practice further validate significance and necessity of the CNS.

Implications for Practice: National core competencies should be incorporated into CNS primary accountabilities, position descriptions and peer review processes. More exemplars demonstrating these competencies are needed to highlight CNS practice, educate entry level CNSs, and evaluate core competencies in action.

Creating an Innovative Statewide Evidence-Based Practice Program

Johnson K, Queens Medical Center, Honolulu, Hawaii

Significance: It is widely recognized that negative outcomes of healthcare can be a consequence of tradition-based practice. Our State Center for Nursing (Center) has a vested interest in supporting nurses in efforts to provide the highest possible quality of care to its residents. However, barriers to the provision of evidence-based practice (EBP) exist. Background/Rationale In 2009, the Center took the lead and partnered with facilities across the state to develop the only state-wide EBP program with the dual purpose of developing an EBP-competent nursing workforce and improving the quality of nursing care to the state's residents.

Methods: Translational science has outlined key elements of a successful EBP culture, such as mentors, partnerships between academic and clinical settings, EBP champions, time and resources, and administrative support. The Center offers annual 2.5-day workshops for 35 RNs who bring to the workshop an identified clinical problem. The workshop agenda is developed by Dr Titler and local faculty and covers each step of the Iowa Model. Workshop attendees, teams usually consisting of a staff nurse, an advance practice registered nurse (APRN), and a nurse manager, subsequently receive ongoing coaching and support from the Center's Project Team via an 18-month internship program as they develop, implement, and evaluate the resulting practice guidelines. Ideally, attendees return to their respective facilities and form multidisciplinary teams. The staff nurse serves as an EBP change champion and must have institutional support, resources, skills, time, cooperation, and peer buy-in. The APRN acts as the opinion leader, assisting with identifying and critiquing the literature and implementation strategies, and the nurse manager provides administrative and logistical support.

Outcomes: Across 14 healthcare institutions, over 100 nurses have been trained, 48 EBP projects initiated, and, 6 have been completed and institutionalized, 6 have been discontinued, and the remaining 36 projects are ongoing and in various stages of implementation. One project is being implemented at 4 institutions and another is being developed across 6 different units within 1 facility. Several teams have successfully disseminated their project results through national and local podium and poster presentations, Center newsletter publications, and textbooks.

Conclusions/Interpretations: The Center's focus is to empower nurses with the skills and knowledge necessary and endowed with the requisite leadership and resources to successfully change practice and improve the quality of care. What is innovative about our EBP program is that it is open to all healthcare facilities throughout the state. Faculty come from a variety of patient care and academic settings. There is a strong component of peer modeling and teaching, thus building a strong foundation for internal facility education and training as well as a change in the culture of nursing practice.

Implications for Practice: The APRN is pivotal in creating an EBP culture and encouraging enculturation of the newly developed EBP guidelines. Mentoring the EBP change champions and coaching staff nurses to address barriers to change are daily encounters. Sustainability of the state-wide EBP program is being addressed through a train-the-trainer model, a role well fitting of an APRN at the state or institutional level.

Cultivating a Safe Patient Handling Culture in a Community Hospital

Halvorson BL, Houlihan A, Riley L, Fox T, Milek C, Hargrove J, Torrance Memorial Medical Center, California

Purpose: Nurses have high rates of on-the-job injuries due to unsafe patient handling. Recent legislation requires hospitals to develop a patient protection and healthcare worker injury policy and prevention plan.

Significance: Creating a culture of safety for patients and staff can lead to reduced injury, improved patient outcomes and cost reduction.

Design: The IOWA Model for Evidence-Based Practice (EBP) and Kaizen quality improvement techniques guided a CNS co-led interdisciplinary taskforce in planning a Safe Patient Handling (SPH) program. The American Nurses Association's SPH resources served as the basis for the program content. Detailed review of the number and types of staff injuries identified high-risk situations (pulling patients up in bed, repositioning/turning, and patient transfers from sit to stand position, etc) which were occurring among various disciplines. Availability of patient lift and transfer equipment was also assessed. As a result, identified program priorities focused on: changing the culture from manual lifting to safe patient handling, incorporating a mandatory interdisciplinary house wide approach, acquiring appropriate/sufficient equipment and training staff on its use, and encouraging proper body mechanics.

Methods: The SPH program utilized a unit champion model and incorporated didactic lecture and hands-on return demonstration of equipment use. A self-learning module was also developed to complement class content. Mandatory training occurred via 2-hour small group classes taught by SPH champions, a CNS, and physical therapy staff. Instruction covered discussion of recent legislation and principles of SPH; nursing mobility assessment, care-planning and documentation; proper body mechanics; and types of patient transfer/lift equipment. Hands-on activities included patient transfer techniques using approved equipment, and patient lift operation. Knowledge mastery was measured via posttest and proficient equipment use was demonstrated by successful completion of skills competency checklists. Roll-out began in January 2012. Regular taskforce meetings and rounds continue to monitor SPH practices and address barriers and challenges to full adoption.

Findings/Outcomes: Over 120 classes were offered; 40 unit champions completed training and greater than 1000 staff attended (83%). All participants achieved at least 95% mastery of program content and over 95% demonstrated competent operation of equipment. Staff feedback was very positive reporting decreased anxiety related to equipment use. Early monitoring of practice change identified the need to distribute equipment based on acuity, increase availability of electrical outlets and lift storage space, increase accessibility to patient slings, increase completion of mobility assessments, facilitate accurate documentation via the electronic medical record, and involve additional disciplines including clinical informatics, central supply, and biomedical engineering. Early monitoring reveals a downward trend in number of employee injuries.

Conclusions/Interpretations: A CNS co-led interdisciplinary taskforce applying the EBP process and Kaizen techniques can create a foundation to facilitate successful cultural change promoting SPH.

Implications: Continued monitoring of SPH practices and inclusion of various disciplines in the process are necessary to promote full adoption and attain desired.

Outcomes: Reduced staff injuries, improved patient outcomes and cost reduction.

A Daily Goals Tool to Facilitate Indirect Nurse-Physician Communication During Morning Rounds on a Medical-Surgical Unit

Perry VL, Franks M, Rasool K, Air Force, San Antonio, Texas

Purpose: To develop a daily goals tool to facilitate indirect nurse-physician communication, at an academic institution medical-surgical unit, when the nurses are unavailable to round that will help improve communication and coordination of care between nurses and physicians about the patient's daily goals.

Significance: Daily bedside rounds are the cornerstone of communication and multidisciplinary care planning in the inpatient setting of academic institution. Although research shows standardized communication tools can help, few hospitals use them, especially in the medical-surgical units. Daily goal communication sheets, has shown to improve communication of current plan of care and provides an opportunity for clinicians to ask questions.

Design/Background: At our teaching hospital, nurse-physician rounding is difficult on our medical-surgical units due to several factors; many physician teams rounding at unpredictable times or several teams rounding simultaneously and nurses unable to coordinate round attendance, physicians spending 15 minutes or longer discussing 1 patient for teaching, or nurse is too busy. For these reasons along with several others, this made it difficult for the nurses to participate in rounds to discuss or hear the patient's plan of care for the day.

Description of Method: A laminated reusable communication tool was developed and posted outside the patient's door. The tool was used only during morning rounds. The nurses would write their nonemergent patient concerns or any information they wanted to relay to the physicians on the tool. When the physicians rounded, they would read the nurses notes and respond on the tool and also wrote the patient's goals for the day. The nurse went back to read what was written and erased the tool for the next day's use. Attending physicians, residents, and nurses completed a questionnaire before and 4 months after implementation. Responses were scored on a 5-point scale (1 = none of the time, 5 = all of the time).

Findings: Before the tool was implemented, scores for communicating patient's care for the day during rounds between nurses and physicians were 2.5 and 2.2, respectively. Scores increased by 3.8 for nurses and 3.5 for physicians. The most significant improvement was the understanding of the goals for the patient: nurses from 38% to 72% and physicians' perception of the nurses' understanding the goals from 27% to 87%. Eighty-one percent of nurses, and 62% of physicians said the tool improved communication between them. Both groups scored the tool as having a moderate positive effect on patient outcomes. Eighty-one percent of nurses and 75% of physicians wanted to continue using the tool.

Conclusion: The daily goals tool helped improved communication between nurses and physicians about the patient's goals and care when the nurses were unavailable to round. It also improved communication and coordination of care between both groups.

Implications: Utilizing a daily goals tool for rounds improves coordination and communication of care between nurses and physicians and offers a venue for the unavailable nurses to voice their concerns during physician rounds.

The Design and Implementation of an Innovative Multidisciplinary Warfarin Patient Education Program

Lake K, Catanese B, Somerset Medical Center, Somerville, New Jersey; Brunetti L, Rutgers, The State University of New Jersey, Piscataway; Dhanaliwala F, Lausin A, Somerset Medical Center, Somerville, New Jersey; Kalabalik J, Somerset Medical Center, Piscataway, New Jersey; and Doherty N, Vigdor S, Somerset Medical Center, Somerville, New Jersey

Significance: Maintaining patients on warfarin therapy is a challenge due to its narrow therapeutic index, frequent lab testing, numerous drug-drug interactions and compliance issues among patients. According to the Institute for Safe Medication Practices (ISMP), significant or fatal adverse drug events (ADEs) associated with warfarin continue to be among the most frequently reported occurrences to the FDA. The 2011 Joint Commission National Patient Safety Goal (NPSG 03.05.01) states that hospitals must "reduce the likelihood of harm associated with the use of anticoagulant therapy." One component of the NPSG is to "provide education to prescribers, staff, patients and families." Background/Rationale Upon tracking and trending medication event data in the organization, opportunities for improvement were identified for patient education regarding warfarin therapy.

Description of Methods: In 2009, an interdisciplinary committee composed of the clinical nurse specialist, pharmacy, information technology and food and nutrition convened to evaluate the current process of patient education for warfarin therapy. In a review of the literature as it pertains to best practice standards, it was identified that patients who were better educated about their warfarin therapy demonstrated better outcomes and less adverse events than those patients with little or no education. The interdisciplinary group focused on developing and implementing an organization-wide Warfarin Education Program (WEP). Initially, the program was targeted at those patients initiated on warfarin therapy and those patients who presented with an INR >5. A booklet discussing key points of warfarin therapy was written and printed in both English and Spanish, an electronic consult was built into the organization's electronic documentation for both nursing and physicians to request a pharmacy consult for warfarin counseling. A dedicated phone line (CLOT Hotline) was set up in the Pharmacy to receive warfarin counseling requests. Pharmacists and pharmacy students were scripted on the key points of warfarin education and perform consults at the patient bedside.

Outcomes: Since its inception in 2010, over 1000 patients have been counseled regarding their warfarin therapy. The volume of counseling supported the creation of an Anticoagulation Elective for students enrolled in a Doctorate of Pharmacy program at a local state university. In another study conducted by the organization regarding venous thromboembolism (VTE) readmission rates, patients who received warfarin counseling demonstrated a 30% reduction in readmission for VTE at 90 days. Conclusion Patients that receive a formal counseling session regarding their warfarin therapy have demonstrated improved clinical outcomes and less adverse events.

Implications for Practice: The current process is that prescribers and nursing staff request a warfarin consult for patients. Future initiatives could include building a trigger into the organization's electronic medical record that "auto-generates" a consult when warfarin is ordered for a patient. Counseling services to be expanded to include additional anticoagulants such as enoxaparin, heparin, dabigatran, rivaroxiban, and so on. Program to reviewed to ensure that it complies with current evidence-based practice standards and regulatory requirements.

Developing Clinical Nurse Specialist Students' Coaching Skills for Facilitating Lifestyle Change

Timmerman GM, The University of Texas at Austin, School of Nursing

Purpose: A structured clinical experience for CNS students that enhances their ability to deliver heath promotion activities designed to reduce risk behaviors and to develop students' coaching skills is described.

Significance: Lifestyle factors (eg, lack of physical activity, stress, poor dietary habits) are often etiologies for non-disease-based illnesses and also increase the risk for chronic diseases (eg, diabetes, heart disease). Thus, CNS students need to develop competencies (eg, expert coaching) to successfully facilitate lifestyle change if they are to effectively provide interventions.

Background: Traditional teaching of patients often includes giving advice (ie, lose weight, exercise more). Yet, advice giving is often ineffective and can lead to resistance. More effective, evidence-based strategies for facilitating lifestyle change are available and should be incorporated into CNS education and practice.

Description: Clinical nurse specialist students are required to separately coach 2 individuals weekly over a 6- to 8-week period to facilitate them making a lifestyle change (eg, weight management, stress management). Students improve their coaching skills by practicing motivational interviewing, choosing theory-based interventions, and providing evidence-based information. Behavioral interventions (eg, goal setting and self-monitoring), cognitive interventions (eg, cognitive reframing, positive self-talk), and educational interventions are selectively used. Through reflection students are able to evaluate the effectiveness of their delivery of interventions.

Outcomes: This clinical experience helped CNS students to improve their ability to be client-centered and to elicit active participation in the development of their coaching skills. Students developed a better understanding of the challenges involved in making lifestyle changes along with the importance of considering the problem within context of the individual's life. Students also improved in their ability to apply health promotion theories in practice, which guided their interventions. Feedback from those receiving lifestyle coaching has consistently been positive.

Conclusion: Coaching clients interested in making a lifestyle change is a useful strategy for improving CNS students' coaching skills, ability to apply theory, along with learning behavioral, cognitive and educational interventions as part of tool kit to facilitate change.

Implications: Clinical nurse specialist students can benefit from educational programs that provide students with opportunities to develop the competencies needed to deliver interventions effective in reducing risk behaviors.

Implementing a Facility-Wide Program for Feeding Tube Placement Reassessment

Perry VL, Ellis KW, Air Force, San Antonio, Texas

Purpose: To change bedside nursing practice of feeding tube placement reassessment and improve nursing knowledge of current recommendations.

Significance: Misplacement and malpositioning of feeding tubes has been reported to occur at a rate of up to 4% for adults and 21% to 43.5% in infants/children. Tube misplacement and malpositioning place the patient at increased risk of aspiration, pneumonia, feeding intolerance, and even death. Air insufflation with auscultation is no longer standard of care for nasogastric feeding tube placement reassessment. Instead, according to research, systematic reviews, and meta-analysis literature, the reassessment process should be multifactorial and include an assessment of the aspirate (volume, color/character, pH) as well as other assessment factors (patient tolerance, tube length).

Background: During the November 2011 hospital-wide nursing skills fair, it became evident that nursing staff was not aware of, nor practicing, the current recommendations. In fact, 364/365 attendees stated they currently use air insufflation to check bedside placement, and only 1/18 inpatient units had gastric pH paper available. Unit leadership reported that the point-of-care testing requirements for bedside aspirate pH testing inhibited the routine use of pH paper on the units.

Method: A standardized, evidence-based, and scenario-based training inservice was developed. Initial wave of staff training began in January 2012 and is ongoing. Training includes the acronym "TAP," which we developed to help staff recall key elements of the feeding tube assessment process: Tube, Aspirate (volume, color/character, pH), Patient. All inpatient units were provided with an initial supply of gastric pH paper and reordering information. The lab department officially waived point-of-care testing requirements. "Air bolus" option was removed from the Essentris documentation screens.

Findings/Outcomes: A pretraining/posttraining assessment questionnaire is completed at the time of training. So far, 136 nurses have been trained (n = 136). Pretraining results: 72% used air auscultation; 17% used pH; 6% used x-ray; 5% did not reassess. Posttraining results: 97% will assess the tube, aspirate (volume, color/character, pH) and patient ("TAP" process); 3% will request x-ray; 0% will use air auscultation. Sixty-one percent stated they would have previously assessed aspirate pH if pH paper had been available on their unit. Ninety-eight percent felt the TAP acronym will help them recall the assessment process.

Conclusion: Initial training results indicate that 97% of nurses demonstrated improved knowledge mastery of feeding tube placement reassessment.

Implications: Reassessment of nasogastric feeding tube placement should include assessment of the tube, aspirate, and patient; air insufflation should not be performed.

Early Recognition and Management of Severe Sepsis on Medical and Surgical Units

McNeill KP, Cole KJ, Sutter Roseville Medical Center, California; Daly MA, Sutter Health Sacramento Sierra Region, California; Petrella RL, Sacramento, California; Pifer TL, Sutter Roseville Medical Center, Roseville, California

Purpose: The purpose of this presentation is to share our organization's approach to reducing mortality through early recognition and management of medical and surgical patients with severe sepsis before it progresses to septic shock.

Significance: Evidence shows that early recognition and aggressive management of sepsis improves outcomes of hospitalized patients. However, symptoms of sepsis are easily attributed to other conditions and often not recognized until they present in a state of septic shock. National data shows a higher mortality rate for inpatients who develop severe sepsis or septic shock on a medical or surgical unit compared with those who present to the emergency department and are admitted directly to the intensive care unit.

Background: In 2010, we began collecting baseline data for our initiative to improve early identification of sepsis in inpatients. Our data showed that patients admitted to medical or surgical units who developed severe sepsis or septic shock had a mortality rate of 25.2% versus those who were admitted directly to the intensive care unit who had a mortality rate of 21.4%.

Description: In 2010, RN sepsis champions from the medical and surgical units began the work of designing and implementing processes to identify patients with severe sepsis and initiate the sepsis bundle. Sepsis champions used the PDSA model as the foundation for changing practice. A screening tool that used a step-by-step approach, beginning with infection and ending with septic shock, was designed to assist the nurse in identifying of the degree of sepsis. The rapid response team's approach was revised to include confirmation of screening results and implementation of the first elements of the sepsis bundle, including lactate level, rapid fluid bolus, and notification of the interdisciplinary team via a new Sepsis Alert. Prior to implementation, sepsis education for nurses included pathophysiology, assessment, and treatment, along with new screening and alert processes. At go-live, new flowsheets were rolled out and sepsis champions provided real-time training on their units. Ongoing monitoring included audits and data collection of all patients with severe sepsis for accurate screening, sepsis bundle compliance, and mortality. Ongoing education was based on audit findings and feedback from staff. As a result, revisions were made to the screening tool, RRT/Sepsis Alert team responsibilities and order sets, while the need for physician education was identified.

Findings/Outcomes: Bundle compliance and mortality were monitored monthly. By the end of 2011, mortality for medical and surgical patients with severe sepsis or septic shock decreased from 25.2% to 12.1%, a 50% reduction in 12 months.

Interpretation/Conclusion: Nurses are vital to the early detection and management of patients with severe sepsis. When nurses accurately assess patients, aggressive interventions can be implemented early to prevent disease progression, thus improving patient outcomes and reducing mortality.

Implications for Practice: Allowing staff to design the process ensures success and compliance. Empowering nurses to speak up for their patients improves morale and confidence in their practice-they trust themselves and their assessment skills because their findings are supported by the evidence of many studies. Together, with evidence-based assessment tools and interventions, nurses have a direct impact on improving patient outcomes.

The Evidence-Based Practice Experience!

Badalamenti SA, Stott S, Banner Thunderbird Medical Center, Glendale, Arizona

Purpose: To create a spirit of inquiry and lead teams though innovation and change in healthcare, a team of clinical nurse specialists conducted a workshop to teach evidence-based practice (EBP) principles and processes. These concepts were taught to RNs new to implementing evidence-based clinical projects on their units.

Significance: Evidence-based practice is an essential component to the healthcare system's mission, vision, and values of providing excellent patient care and positively impacting patient outcomes. This workshop was a significant step to reduce variances in EBP processes and interpretation of results.

Background: The Joint Commission acknowledges the use of EBP as an effective way to improve healthcare outcomes. Our organization is seeking Magnet recognition. The Professional Practice Department, lead by 3 clinical nurse specialists, in collaboration with the Magnet New Knowledge and Innovation committee developed a 4-day workshop to empower RNs with education, tools, and mentorship to advance their EBP unit projects.

Methods: The workshop was divided into four 4-hour sessions over a 4-month period. We used Banner Health's EBP ENSURRE Clinical Practice Model to guide the content. Mentoring between sessions facilitated progress on the projects. Time was allotted for developing PICOT questions, synthesis tables, Change Acceleration Process tools, SMART goals, and data collection methods. Nine teams were encouraged to participate in the workshop from 5 clinical areas, including NICU, maternal child health, medical-surgical, PCU, and ICU. Also, 2 clinical teams, wound and pain, participated. We used a Disney-themed approach to create an EBP "experience" for the nurses.

Outcomes: Nine clinical questions were identified with 8 developed into EBP projects. One clinical question was recognized as research. Two projects are near completion. The 6 other EBP projects are in various stages of completion. The research project team is writing the institutional review board protocol. The teams are expected to disseminate their outcomes internally, as well as encouraged to present at a national conference.

Conclusions: All 9 teams continued through the evolution of their projects. Feedback from each session was positive. One makeup session was conducted to provide the same education and training for those team members who missed previous sessions.

Implications: The success of this workshop has created a spirit of inquiry throughout the facility. The workshop will be offered throughout the 22 facilities in 7 states in a large healthcare system.

Effective Strategies to Reduce Bleeding/Vascular Complications Post-Cardiac Catheterization

Gumersell K, Stony Brook Medicine, New York

Purpose: Bleeding/vascular complications after cardiac catheterization can result in significant adverse patient outcomes associated with high financial cost. The objective was to develop successful strategies to reduce the after cardiac catheterization complication rate.

Significance: Bleeding and vascular complications related to cardiac catheterizations result in serious injury to the patient and these injuries come with economic costs. Minor bleeding complications can cost $2900 to $4300 with major bleeding complications costing $7000 to $14 000. These patients must undergo additional diagnostic imaging, additional lab costs, blood transfusions, vascular repair, an increased length of stay and delayed return to work.

Background/Rationale: Managing bleeding/vascular complications related to after cardiac catheterization can be crucial to quality patient outcomes. Establishing strategies to both prevent complications and minimize harm were essential to reduce complication rates.

Description: Opportunities were identified and an action plan was developed to include data collection on all complications, the development of a complication card and drill down documentation. Daily access rounds by the clinical nurse specialist were initiated on all after cardiac catheterization patients. Utilizing the American College of Cardiology definition of access site injury/bleeding was utilized for standardization. Ongoing education and reporting structure for complications were established. Strategies were developed to include preassessment, technique, access identification, sheath removal procedure, hematoma management, and early recognition of retroperitoneal bleed with aggressive treatment, after cardiac catheterization assessment, improved documentation, radial access and increased use of Bivalrudin.

Outcome: Strategies have been effective reducing the complication rate of 1.5% to 0.8% over 12 months.

Interpretation/Conclusion and Implications for Practice: Clinical nurse specialist-driven model has had significant reduction in post-cardiac catheterization complication rate, improving quality patient care while decreasing costs to the institution related to complications and length of stay.

Effects of a Teambuilding Class on a Progressive Care Unit's Healthy Work Environment

Leary S, San Diego VA Healthcare System, San Diego, California

Purpose: The purpose of this project was to improve the healthy work environment among staff in a progressive care unit by implementing a teambuilding class, called TeamSTEPPS.

Significance: According to The Joint Commission's Sentinel Event Database, inadequate communication was the root cause of 65% of 3811 reported sentinel events, with 75% resulting in the patient's death. In 2005, the American Association of Critical-Care Nurses prioritized a healthy work environment initiative to support and foster excellent patient care by addressing 6 components: skilled communication, authentic leadership, meaningful recognition, appropriate staffing, and true collaboration. The Joint Commission suggests that patient safety and staff satisfaction can be improved through teambuilding. TeamSTEPPS is an evidence-based teamwork system developed by the Department of Defense and Agency for Healthcare Quality and Research.

Design: The design for this evidence-based project was a descriptive, cross-sectional, nonexperimental survey design with a sample size of 33 RNs. The following PICO question was used: "Will the implementation of a teambuilding class improve the staff's perception of a HWE on the posttest assessment?"

Description of Methods: The pretest-posttest instrument used was the Healthy Work Environment Assessment Tool to anonymously survey staff. The survey consists of 18 questions with a Cronbach [alpha] of .80, used to evaluate the work environment. The CNS facilitated an interactive, 4-hour class to the progressive care unit's staff: RNs, telemetry technicians, unit clerks, pharmacists, and environmental service team members. The content included an introduction to healthy work environment and TeamSTEPPS. The components of TeamSTEPPS included leadership, situational monitoring, communication skills, and mutual support aids. Multiple teaching methods were used to facilitate communication to include lecture, scenarios, scripting, mnemonics and prompts to aid in building better communication skills.

Findings/Outcomes: The presurvey was completed by 24 RNs with an overall score of 3.4. The postsurvey was completed by 33 RNs with an overall score of 3.7. All 6 subscales showed improvement from presurvey to postsurvey assessment. Staff members unable to participate in the survey anecdotally reported increased successful use of newly acquired techniques from TeamSTEPPS classes in improving communication among caregivers.

Conclusions/Interpretations: The implementation of the teambuilding class improved the staff's perception of the healthy work environment, as evidenced by the posttest assessment and anecdotal reports.

Implications: Recommendations include clinical nurse specialists seeking to improve staffs' work environment's offer an educational, teambuilding opportunity to increase staff's perception of a healthy work environment. An increase in healthy work environment may lead to a decrease in turnover rates and increased job satisfaction and could potentially improve patient outcomes.

Effects of Health Promotion Intervention for Cancer Survivors

Meraviglia M, University of Texas at Austin

Purpose: the purpose of the study was to pilot test a theoretically-based health promotion (HP) intervention (development participant/provider support relationships, weekly HP classes for 6 weeks and telephone follow-up support for 2 months).

Significance: Many people in the United States have difficulty maintaining their health during the cancer experience because they encounter multiple barriers to acquiring or participating in health-promoting behaviors. Socioeconomic factors (eg, low income and lack of health insurance) are especially difficult to overcome and are associated with lower use of healthcare, poorer overall health, and shortened survival. Promoting healthy behaviors of low-income persons provides them with information and support to enhance their health and quality of life.

Design (Background/Rationale): Randomized controlled trial of low-income cancer survivors

Description of Methods: After giving consent to participate, people who had been diagnosed with stage 1-3 cancer at least 6 months completed a study packet assessing personal and cancer characteristics, HP behaviors, self-efficacy for engaging in HP behaviors, and outcome variables (physical health, functional health, and quality of life). Participants were randomized to either the HP intervention or control group. Data analysis examined changes over 3 time periods as well as group x time interactions using repeated-measures analysis of variance in SPSS.

Findings/Outcomes: To be included in the final sample for analysis of the intervention, participants had to complete data collection at all 3 time points and attend at least 50% of the classes. The final study sample was 35 (15 intervention, 20 control). Participants in the intervention reported the health-promotion classes were very helpful and relevant. A significant interaction effect was found for the total Self-rated Abilities Scale, suggesting that across the 2 follow-up occasions, individuals in the intervention reported on average greater levels of self-efficacy. Significant intervention effects were found for the Health Promoting Lifestyle Profile II (HPLPII). Total health-promoting behavior scores increased over time, whereas the health-promoting behavior scores for the control remained constant. A significant time x group interaction was present, which suggests that the intervention and control groups differed in terms of how their total health-promoting behavior scores changed. Significant intervention effects were found for the HPLPII subscales responsibility, physical activity, nutrition, and stress management. A time x group interaction occurred for the responsibility and physical activity subscales, suggesting that individuals in the intervention group reported greater levels of responsibility and physical activity over time. The effects of the intervention on quality of life, an outcome variable, was significant for the total Functional Assessment of Chronic Illness Therapy-General scores, but not for the subscales.

Conclusions/Interpretations: The intervention was successful in improving self-efficacy, health behaviors, and quality of life over time. The most substantial changes were in aspects of self-efficacy and performance of health behaviors.

Implications: Findings will guide further refinement of the intervention and demonstrates positive benefits for providing cancer survivors information, skills, and support they need to improve their health and quality of life.

Elicit-Provide-Elicit: Using a Motivational Interviewing Technique to Assist Patients Understanding of Fall Risk

Woodard JL, Indiana University Health, Plainfield

Purpose: The purpose of this study was to test the feasibility of use of a motivational interviewing (MI) technique used in interactions with patients around fall risk in the hospital setting. The objectives of this presentation are by then end of this discussion the learner will: (1) Understand a MI technique of elicit provide elicit (EPE). (2) Apply EPE to conversations with patients about fall risk. (3) Explore results of small study using EPE in fall risk patient conversations.

Significance: Motivational interviewing is a form of counseling that has been found to be effective in changing a wide range of health behaviors. It is a style of conversing with a patient to reveal the patient's goals, values and aspirations. A technique within MI to gain the patient's perspective of fall risk and safety in the hospital setting is the EPE technique. Information exchange begins with an open-ended question to focus the nurse's informing about fall risk. An area hospital fall prevention programs lack is the patient involvement in the process of identifying risk and goal setting to prevent falls. More importantly, no assessment to identify what this information means to the patient is practiced. Allowing patients to become a part of the hospital's fall prevention program emphasizes the patient's active involvement in their own care and motivates them to participate with the nurse to remain safe and fall free during the hospital stay.

Design (Background/Rationale): Registered nurses (RNs) completed a class to learn EPE and gain understanding of its impact on fall risk. The nurses utilized this method of EPE in their interactions with patients at risk for falling. After nurses communicated with patients, they recorded a goal set by the patient. The nurse then rated the patient's ability to maintain the goal using a goal attainment scale. Feasibility of using EPE was evaluated by the RNs using a tool developed for the study.

Description of Methods: A feasibility/usability study of EPE was conducted in the acute care setting of a Midwestern community hospital. RNs learned the pieces of EPE in regards to usability of this technique to keep patients fall free during their acute care stay. Open ended questions to elicit the patient's understanding of their own safety started the RNs conversation.

Findings/Outcomes: Five RNs participated in the study, completing 2 surveys: Feasibility/ease of use questionnaire: 4/5 not difficult at all to learn EPE; 2/5 not difficult at all to use EPE. Nurses found EPE useful; 4/5 said somewhat useful; 1/5 very useful Goal Attainment Scale: 4/5 patient's goal was to call before getting out of bed. One patient stated, "I can tell you the adverse effects of taking Ambien-it makes me dizzy." None of these patients experienced a fall. Both participating units outperformed NDNQI mean for total falls during the study period.

Conclusions/Interpretations/Implications: As EPE becomes part of the RNs normal, daily conversation about fall risk and safety, patient compliance with the interventions will occur because the patient is included in their own fall prevention plan. The platform of EPE is to inform the patient using knowledge the patient already has about the topic using open-ended questions. EPE is a skill that when perfected by RNs, has a lasting impression on the patient's ability to manage their own safety during the hospital stay.

Eliminating Elective Deliveries Less Than 39 Weeks: A Nonprofit Community Hospital's Journey

Tincher BM, Trinity Mother Frances Hospital, Whitehouse, Texas

The purpose of this poster is to share how a nonprofit community hospital dealt with significantly reducing elective deliveries less than 39 weeks' gestation. The significance of addressing this issue is to prevent iatrogenic prematurity, a cause championed by the March of Dimes. The design of this interdisciplinary team included a nurse administrator, nurse champion, nurse data abstractor and physician champion. Methodology included engaging the obstetrics/gynecology section with strong administrative support in creating a policy and process for defining acceptable reasons for medically necessary inductions and the scheduling of all elective deliveries regardless of gestational age. A proactive approval process and retrospective review of all elective deliveries ensures compliance. This hospital has reduced elective deliveries less than 39 weeks from 20% to 2% exceeding the national threshold of no more than 5% elective deliveries less than 39 weeks' gestation. The benefit to the newborn has profound implications when prematurity is prevented. Additional implications can be prevention of morbidities for the newborn and a significant savings in healthcare costs when NICU admissions are avoided. The role of the Maternal Child CNS was pivotal as she fulfilled the role of nurse champion and clinical liaison with physicians and staff during planning, implementation and fine tuning the process.

Empowering and Transforming Future Clinical Leaders

Solomon D, Klein D, Cleveland Clinic, Ohio

Purpose: The clinical nurse specialist (CNS) is in an ideal role to help transform the workplace as called for by the Institute of Medicine in The Future of Nursing: Leading Change, Advancing Health. In all 3 spheres of influence, patient, nurse, and system, the CNS can actively work in the role of a transformational leader by being an effective communicator, possessing inspirational traits, having a trustworthy character, and promoting teamwork. The CNS can empower the staff nurse to practice to the full extent of their education and training. In our presentation, we seek to reinforce the CNS voice and sense of empowerment.

Significance/Background or Rationale: In our regulatory environment, it is no longer a luxury but a necessity to push the staff nurse to perform utilizing their skills and evidence-based practice. The CNS possesses the tools to advance nursing practice by sharing their power to improve professional responsibilities. Transformational nursing leadership is required to influence and change the status quo. The roles of the transformational leader is to encourage positive self-esteem, motivate staff to function at a high level of performance and empower staff to become more involved in the hospital system through practice councils, journal clubs, and an expert to achieve improved patient outcomes.

Description: Through dynamic dialogue and interaction, 2 experienced CNSs will describe transformational leadership and empowerment in the CNS role. Many examples of how a CNS can influence and transform the staff nurse will be discussed.

Outcome: The CNS in the audience will recognize the strategies to become a transformational leader and empower nurses to be future leaders. Traditional paths are through shared governance councils, journal clubs, mentoring of clinical experts, and promotion of healthy work environments. True empowerment of staff nurses can come from the interaction between the staff nurse and the CNS.

Interpretation/Conclusion: The CNS is well positioned to be in the role of a transformational leader and empower the staff nurse to practice to the full extent of their ability.

Implications for Practice: Identification of self as a leader will encourage more CNSs to influence the future of nursing and help transform the workplace.

Enhancing Evidence Appraisal Skills Through Clinical Nurse Specialist Student-Led Journal Clubs

Huffman D, Eastland T, Hopp L, Purdue University Calumet, Hammond, Indiana; Walker J, Hammond, Indiana

Purpose/Objectives: The aim of this presentation is to describe how faculty can use a journal club assignment to develop evidence appraisal skills necessary for effective clinical nurse specialist (CNS) practice.

Significance: Clinical nurse specialists need to possess solid evidence appraisal skills. One way to help CNS students achieve these skills is through experiential learning opportunities. Leading undergraduate students in a journal club discussion is 1 way to provide this type of learning experience.

Background/Rationale: Faculty teaching CNS students recognized that journal clubs can be a valuable way to help build evidence appraisal skills. For many years, our CNS students led journal club discussions among their peers. This peer-led journal club assignment provided opportunities for critical appraisal, but group discussion was sometimes limited. Seeking to improve this learning experience, CNS faculty explored journal club opportunities with faculty teaching the baccalaureate research course.

Description of Methods: We revised the existing CNS student journal club assignment by having CNS students lead journal clubs with baccalaureate nursing students enrolled in their nursing research course. Faculty from both programs jointly select research articles to be appraised and discussed. Students appraise both qualitative and quantitative primary research reports. Depending on the articles' research design, students use either the qualitative or quantitative version of the CASP evidence appraisal tool. Journal clubs take place within small groups with faculty monitoring the discussion. Immediately following the journal club, students reassemble for faculty-led debriefing sessions.

Findings/Outcomes: This journal club experience has been positive for both CNS and baccalaureate students. For example, CNS faculty have reported improvements in critical appraisal and the quality of class discussions. Additionally, CNS students have reported increased confidence in their appraisal skills and have requested additional journal club opportunities. This experience has also prepared students to lead journal clubs in their practicum settings. What began as a pilot assignment is now fully embedded within the CNS courses and the baccalaureate research class.

Conclusions/Interpretations: Feedback from CNS and baccalaureate students has been consistently positive, and several CNS alumni have returned following graduation to participate. In addition to enhancing appraisal skills, this opportunity has allowed CNS students to further develop their leadership abilities. The faculty remain committed to this learning activity and are exploring virtual journal club opportunities for distance students.

Implications: Providing opportunities for CNS students to lead journal clubs while in their basic program can be an effective way to enhance evidence appraisal skills. In addition, this experience can assist CNS students in working with groups and serving as role models to baccalaureate nursing students.

Enhancing Self-care Practices in Heart Failure Patients

Zavertnik JE, Virginia Commonwealth University, Richmond

Purpose: The purpose of this quality improvement project was to provide an enhanced discharge education plan and home follow-up to promote self-care in heart failure patients.

Significance: Improving self-care behaviors of heart failure patients can improve healthcare outcomes. Early recognition and treatment of heart failure exacerbation can decrease hospital readmission.

Design (Background/Rationale): One hundred heart failure patients, through an ancillary services grant, were provided with resources for home self-care monitoring: a bathroom scale, a graduated drinking cup, a monthly log book for recording weight and symptoms, and a written education information. The patients were educated on how to monitor symptoms using a teach-back method. Patient agreed to be called at home weekly for 1 month.

Description of Methods: Follow-up phone calls were done by a clinical nurse specialist within 72 hours of discharge and weekly for 1 month. Data were gathered on compliance with self-care activities. Patients were asked rate the "helpfulness" of the teaching and home follow-up.

Findings/Outcomes: Patients in the project did adhere to weight and symptom monitoring and notification of provider of worsening heart failure. Patients thought the project was "very helpful." The staff nurses involved in the project verbalized an increase satisfaction in being able to provide patients with resources to practice self-care behaviors. Discharge education commenced earlier in the patient's hospitalization.

Conclusions/Interpretations: By providing the resources needed to monitor signs and symptoms of worsening heart failure, the project improved patient's self-care management in terms of being able to recognize a change in their condition and take appropriate action.

Implications for Practice: Nurse-led initiates can enhance self-care practices of heart failure patients. Using limited financial means, nurses can make an impact on the healthcare outcomes of the heart failure population.

Entry-Into-Practice: The New Kids on the Block

Falder K, Selimos A, Children's Medical Center Dallas, Texas

Purpose: The purpose of this presentation is to describe the successful orientation of 2 novice CNSs entering into a growing practice within 2 established specialty units (gastroenterology and cardiac) at a large metro children's medical center.

Significance: The concept of the clinical nurse specialist has fluctuated over the past 60 years and has been steadily reemerging since the late 1990s. The recent expansion of CNS utilization over the past decade has increased the need for successful orientation programs and continued support from CNS colleagues after completion of orientation.

Background: There are many documented challenges for the new CNS entering into practice throughout literature. In addition to the currently documented challenges, the novice CNS now faces new hurdles with the economical changes in healthcare. Despite a formal education, the realities of a novice CNS establishing a new role can be challenging. The success of the new CNS is highly influenced by the existence of a formalized orientation and the support of an established CNS network within the institution. This presentation was guided by the From Limbo to Legitimacy Model.

Methods: The formal CNS orientation is a 3-month process to include socialization into the institution and specialty unit. The process consists of formal meetings with key stakeholders led by the CNS manager. Members of the multidisciplinary team, key stakeholders, and CNS team members are shadowed throughout the 3-month period. An advanced practice competency checklist is completed, and SMART goals are also established with the CNS manager based on priorities of the unit. The new CNS is immediately integrated into select committees and councils for socialization into the system. Monthly meetings occur with the CNS manager, unit manager, and director to discuss current and future projects. The entire CNS team also meets regularly on a monthly basis where a mentor-mentee relationship is established. Project selection is crucial for the new CNS to focus on achievable projects in order to avoid over commitment and improve likelihood of success. Each specialty CNS (gastrointestinal and cardiac) conducted a needs assessment through direct observation, meetings with key stakeholders, quality data, and results from the patient/family satisfaction survey. Results from the assessments led to project selection.

Outcomes: Successful completion of the orientation process and integration into the system resulted in appropriate project selection for the novice CNS.

Conclusions: The existence of an established CNS group and formal orientation process enabled 2 novice CNSs to successfully integrate into the system and begin new roles.

Implications: The next generation of clinical nurse specialists can greatly benefit from the knowledge obtained after this entry-into-practice experience. If a similar orientation process is replicated, it can improve the probability of success for not only the novice CNS, but also the experienced CNS and the entire organization.

Every Second Counts: Innovations to Increase Early Defibrillation Rates

Borak M, Bednar V, Beschorner J, Francisco MA, Li S, Lowder E, Maroney M, Pakieser-Reed K, Stokas MA, Barnes MR, University of Chicago Medicine, Illinois

Purpose: To increase timely utilization of automated external defibrillators (AEDs) by medical-surgical staff nurses.

Significance: In-hospital cardiac arrest occurs about twice as often as out-of-hospital cardiac arrest and is associated with poor survival rates. American Heart Association recommendations for cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia call for early defibrillation, manually or with an AED within 2 minutes. Of the cardiac arrests that occurred in medical-surgical areas in our institution in 2011, utilization of the defibrillator in AED mode occurred in only 15% of the cases prior to resuscitation team arrival. Registered nurses, as first responders, must be prepared to perform early defibrillation on medical-surgical inpatients in cardiac arrest.

Design: The AED has primarily been used outside the hospital for timely defibrillation. Early defibrillation programs using AEDs are being established in hospitals. While our institution initiated a number of programs to increase usage of AEDs since 2010, minimal improvement in clinical practice occurred. Thus, an innovative approach was instituted.

Methods: The innovative approach included: *Employment of a designated resuscitation nurse, who facilitates quality improvement resuscitation efforts, monitors resuscitation data, supports staff education and disseminates results. *Provision of high-fidelity simulation-based education program (30 minutes) as part of annual nursing competencies (n = 356). The program included review of unit-specific cardiac arrest statistics, reinforcement of basic life support principles including demonstration of AED use, and emphasis on defibrillation within 2 minutes. Additionally, each nurse responded to a cardiac arrest simulation utilizing a high-fidelity manikin. Performance was evaluated by recognition and activation of emergency assistance, initiating compressions, placement of the AED, and defibrillation. Remediation occurred until all nurses successfully performed these tasks within 2 minutes. *Implementation of ongoing sustainability efforts: Inclusion of clinical nurse specialists, clinical nurse educators and the resuscitation nurse as clinical support to cardiac arrest events, monthly review of unit-specific cardiac arrest data with nurses, interdisciplinary monthly cardiac arrest case discussion, and monthly education of new nursing employees.

Outcomes: All nurses and managers in groups of 2 to 3 completed the simulation event. While the majority of the groups successfully completed the simulation in 1 attempt, 35% of the groups required remediation to successfully complete the competency within the 2-minute time frame. Evaluations indicated that 93% of the staff felt they learned a great extent from the simulation. Analysis of cardiac arrest event data revealed the utilization of the defibrillator by nurses prior to the resuscitation team arrival in 2012 has increased almost 3-fold, compared with 2011 (57% vs 15%). Our preliminary data suggest that early defibrillation by nurses contributes to early return of spontaneous circulation in multiple events.

Conclusions: High-fidelity simulation education, increased clinical support, and a designated individual coordinating ongoing resuscitation efforts resulted in increased timely defibrillation of cardiac arrest patients.

Implications: Our approach can serve as a model for other institutions challenged to improve early defibrillation rates.

Facilitating Self Care in CNS students

Cadman SJ, Regis College, Hollis, New Hampshire

Purpose/Objectives: The purpose of this presentation is to share strategies on promoting self-care practices in CNS students. Significance CNSs in practice facilitate the development of nursing caring practices through role modeling, coaching and mentoring but CNS students may not understand that caring practice begins with self-care. Many CNS students have ongoing stress from the competing demands of clinical practicum hours, course assignments and regular work hours and fail to adopt self-care strategies that promote wellness and successful completion of CNS course work.

Design/Background/Rationale: CNS faculty investigated self-care behaviors in CNS students and found opportunities for growth. Using data from course evaluations, illness/absence records and a review of the literature, a CNS self-care bundle' was developed and added to the curriculum. The purpose of the bundle is to facilitate understanding and the adoption of self-care practices within the CNS cohort and includes: Setting intention, facilitating presence, development and evaluation of a personalized self-care plan, connection and sharing sessions with past CNS graduates, in-class experience with complementary therapies for stress relief, coaching by CNS faculty in self-care practices throughout nine months course work.

Methods/Description: CNS faculty coach students in adoption of self-care practices and help students navigate transitions and anticipate possible challenges to the implementation. Past graduates share proactive strategies that assisted in successful completion of the CNS program. Through discussion, support exercises and coaching, students are empowered to create their own optimal healing self-care plan. Faculty facilitate student experience with complementary therapies designed to reduce stress.

Findings/Outcomes: Since implementation of the self-care bundle in the CNS curriculum in 2009, on time graduations and data from evaluations support the usefulness of a self-care plan for CNS students.

Conclusions: The use of a self-care bundle provides CNS students with a proactive strategy for health promotion and wellness. Future research is needed to evaluate the impact on CNS practice.

Implications for Practice: Implications Facilitating the adoption of self-care practices in CNS students has the potential to positively impact the health and wellness of the CNS throughout their professional life.

Facilitating the Transfer of Expert Knowledge and Practice in Complex Stoma Care Using the 3 C's: Consulting, Collaborating, and Coaching

Trevellini AC, St Francis Heart Center, Roslyn, New York

Objectives: Learner will identify 1 example of how the CNS utilized consulting, collaborating, and coaching to teach patients complex stoma care.

Background: Skin irritation and leakage are reported as common problems contributing to decreased adherence of ostomy appliances. This domino effect negatively impacts the ostomy patient's overall quality of life. Problem identification and timely intervention facilitates discharge, prevents readmission, and improves quality of life for the ostomy patient.

Description: A 300+-bed acute care heart center experienced an expansion of general surgery cases. With expansion came an increase in fecal/urinary diversions. Cases were complicated, often requiring complex stoma care interventions not easily communicated in writing. The CNS collaborated with the clinical nurse to identify complex stoma care needs of postsurgical patients. The CNS group was challenged to establish innovative approaches to consistently communicate interventions to nursing staff and patient/family. The CNS consulted the CWOCN Specialist to establish individualized plans for each patient. This lead to a project focused on creation of individualized photographic tutorials as clinically efficacious coaching tools used to promote continuity/consistency among caregivers while improving patient satisfaction. With patient consent digital photographs were taken to illustrate stoma care. The photographic tutorials were organized in PowerPoint format, step-by-step digital photographs and bulleted directions of care. Plan was devised, stoma care photographed, and color copies of tutorial provided to the patient and interdisciplinary team.

Outcome: This creative and innovative approach to communicating complex stoma care proved a valuable coaching tool. Collaboration of the CNS, CWOCN, clinical RN, care manager, and patient/family optimized clinical outcomes for the ostomy patient. The evidence-based tutorials were developed through consultation with CWOCN and proved instrumental in preventing hospital readmission, decreasing length of stay, and facilitated transfer to rehabilitation and home health agencies. Through consultation, collaboration, and coaching the CNS lead clinical project positively impacted the ostomate and family/caregiver progress towards independent stoma care.

Interpretation/Conclusion: As consultants the CNS and CWOCN Specialist utilized their advanced knowledge to develop and implement teaching strategies which facilitate focused problem solving. Collaborating with other member of the healthcare team provides an avenue of communicating complex stoma care and resolving clinical concerns. The CNS and CWOCN act as a coach to other healthcare team members, patients and family by utilizing the digital photography of step-by -step individualized tutorials.

Implications for Practice: Through consultation, collaboration, and coaching the CNS and CWOCN established a practical tool for communicating complex stoma care. The tutorials have been utilized as teaching tools for advanced stoma care in a didactic setting. The CNS and CWOCN plan to produce additional tutorials for complex stoma cases. The tutorials will be utilized in patient and healthcare provider education.

Family Caregivers Advocating for Older Adults in the Healthcare System: What Strategies Work?

Messecar DC, Oregon Health and Sciences University, Portland

Purpose: Describe the strategies that family caregivers report using to make sure the needs of older adults are met by the healthcare system.

Significance: Caregiver advocacy can make a huge impact on the likelihood of receiving quality care. However, it is not well known what types of advocacy caregivers engage in and or how effective their strategies are in obtaining needed services, equipment, and care. Information from the caregiver's perspective is needed about what advocacy strategies they have tried and how well these strategies work.

Background: Nine focus group interviews with 43 caregivers were conducted to describe caregivers' experiences with advocating for older adults in the healthcare delivery system.

Methods: Nvivo 8 was used to analyze the interview data. Charmaz (2006) approach to coding data was used to organize and categorize the findings.

Findings/Outcomes: Caregivers used several strategies to advocate for the needs of older adults in the healthcare system. These strategies included: being pushy and not easily dissuaded; not easily giving up and insisting on being heard; being present during encounters (doctor's visits, at the bedside in the hospital); and learning how to be persuasive on the phone and in person. About being pushy and not easily dissuaded, 1 son said "it's[horizontal ellipsis] a matter of how pushy you choose to be, because[horizontal ellipsis] you may or may not get the services you need[horizontal ellipsis] [the first time you ask]." When caregivers talked about not easily giving up, they described being persistent even after initially being refused. They often did this by reframing the issue with either the provider or some other intermediary for the healthcare system. For example, several caregivers would call back at a later time, ask to speak to someone else, or go in person say, if they had been brushed off on the phone. One daughter said: "it was something you just have to keep after." Being present when the older adult was being seen by the provider or in some way interacting with the system also was very helpful. As 1 son said, "a lot of times the doctors, when they're talking to seniors, they never directly talk to that person[horizontal ellipsis]." Learning how to be persuasive was another skill that was critical, especially with third-party payers like insurance companies.

Conclusions: The strategies that caregivers found most useful involved being both insistent and persistent, but many lacked the confidence to this.

Implications: Nurses should act as coaches to help family caregivers master the strategies that other caregivers have reported worked for them in getting the needs of the older adult met. Since many lack the confidence to use these strategies, role playing and other simulation techniques can be used by the nurse to help the caregiver practice these strategies. Caregivers might also write out what they plan to say in a script to prepare for a difficult healthcare system encounter. Follow-up and feedback can be used to further build the caregiver's skills using these strategies.

Five Years Later: Has an Evidence-Based Protocol Improved Care for the Adult Sickle Cell Population?

Humphries LA, Texas Health Southwest Fort Worth

Purpose: To evaluate the effectiveness of a Sickle Cell Protocol we implemented at our community hospital in September of 2007.

Significance: Adults with sickle cell disease have a difficult time finding consistent care, primary physicians who understand their condition and often use the emergency rooms to seek care for their condition. Pain is usually the chief complaint for patients experiencing sickle cell crisis. Once admitted to the hospital the sickle cell patient often encounters varying attitudes, inconsistent treatment, and high lengths of stay.

Background: The average length of stay for the adult sickle cell population at our hospital was 12.78 days in 2007. Staff, physicians and patients were frustrated with inconsistent care and treatment. Texas Health Southwest Hospital developed a task force in 2007, facilitated by the clinical nurse specialist to explore best practice, and develop an evidence-based protocol to address treatment and early and aggressive pain management intervention.

Description: The protocol consists of a 5-day length of stay plan of care with an emphasis on quick and aggressive pain management, rapid identification and management of secondary complications, and team approaches to ensure continuity and consistency of care. The clinical nurse specialist facilitated the task force, developed the protocol, and follows each sickle cell patient throughout their stay and any repeat visits as well. The CNS tracks data. The CNS facilitated a citywide taskforce, which resulted in the opening of a Sickle Cell Clinic in 2010 at the county hospital. Hospitals throughout the city are able to refer patients to the clinic for consistent follow-up care. In addition, the adolescents transitioning for the children's hospital are referred to the clinic to continue care as an adult.

Outcome: Our hospital lengths of stay and variable direct costs immediately improved and 5 years later we continue to keep our average length of stay below 5 days. The opening of the Sickle Cell Clinic has provided a place to refer the patients who do not have primary care physicians or need consistent follow-up care. A Sickle Cell Symposium is held annually for the past 4 years to raise awareness in the medical community on best practice for sickle cell management.

Interpretation/Conclusion: There was a slight increase in length of stay for 2012 as of August. The main reason for this rise is believed to be the closing of the only other hospital that serviced Southwest Tarrant County in March 2010. Our hospital has had new patients who are not familiar with the protocol. In addition, new hospitalists, who are the primary admitters for the inpatient side, must be oriented to the protocol and may cause some delay in early pain management.

Implications for Practice: Developing guidelines for the adult sickle cell population has proven to be effective for delivering consistent quality care. Management of sickle cell patients continues long after the patient is discharged. Referral to a sickle cell clinic has helped provide continuity of care.

Four Dimensions: Strategies for Working With The Client Who Has Chronic Pain

Laskowski C, Brien Center, Pittsfield, Massachusetts

Purpose: This theoretical presentation is based on the author's research relating to "difficult" client behavior. The paper was developed to summarize and expand upon theories derived from previous qualitative research done by the author.

Significance: Chronic nonmalignant pain is a problem across most clinical areas and across all client groups. Not only does chronic pain create a financial burden (in terms of tests, treatments, absenteeism, presenteeism), but it also evokes caregiving fatigue.

Design: Qualitative research done with CNSs working with the "difficult" patient and qualitative research done with individuals experiencing symptomatic hepatitis C form the background for this theory-based paper.

Methods: Grounded theory built on previous research done by the author and review of literature.

Findings/Outcomes: As Heidegger (1996) observed, using the analogy of the hammer, our attention is drawn to the times when we hit our thumb rather than the nail. We have much to learn from those times of discomfort, confusion, and pain. This learning can be guided by a 4-dimensional framework: looking at (assessment), looking with (empathy), looking in (self-reflection), and looking around (context). Looking at, the dimension most of us are quite familiar with, can be influenced by cognitive and affective errors. Cognitive errors include Groopman's (2007) discussion of confirmation error and vertical line thinking, and Croskerry's (2003) "zebra retreat." Affective errors easily occur when we particularly like a client (see, eg, Radner, 2000) or dislike a client. Looking With allows us to engage clients on levels that are profound and healing-both for ourselves and our clients. The Jungian archetype of wounded healer speaks to this complicated process (Laskowski and Pellicore, 2002). Looking in involves self-reflection. "What am I feeling when I speak with this client?" "What, about this interaction is 'pushing my buttons'?" Looking around, a dimension often missed in our clinical settings and in our clinical practice, has to do with paying attention to where our clients are "coming from." Social support, emotional distress, feedback loops, and identifying "who is the real patient" can only be recognized if we take the time to look around. Often, inviting family members to join in for the appointment can be enlightening (Rolland, 1995).

Conclusions: The clinician can expand her/his understanding of and treatment of the client while cultivating self-care and duly diligent practice by using techniques related to each dimension. For example-looking at: speak out loud about your questions and considerations regarding treatment. Looking with: "move in" when you have a strong desire to "move out." Looking in: find at least 2 colleagues who you can speak with, honestly and openly, about your insecurities. Looking around: if possible, make a home visit when you are confounded by a certain client's presentation.

Implications: Using these 4 dimensions when working with individuals who have chronic pain can promote higher quality outcomes. In addition, these have the potential to allow for a richer, satisfying practice.

Initiating an Early Mobilization Program in an Intensive Care Unit: A Multidiciplinary Approach

Young S, The Johns Hopkins Hospital, Baltimore, Maryland

The TRiP (Translating Research into Practice) methodology was used in a surgical intensive care unit (ICU) to implement an early mobility program using a multidisciplinary approach. The clinical nurse specialist (CNS) collaborated with a multidisciplinary team to introduce the evidence that early mobilization in a medical ICU decreased ICU and hospital length of stay, maintained preadmission functional status, and was cost effective. Initiating the same program in a surgical ICU was attempted to see if it was feasible and safe. A secondary program goal, in addition to seeing if we could duplicate the MICU (medical intensive care unit) outcomes, was to improve patient outcomes by preventing delirium, ventilator-associated pneumonia, and pressure ulcers. A multidisciplinary team was created to identify barriers to implementation and solutions to those barriers. Baseline performance was measured. Pilot tests were developed to measure outcomes and monitor any improvements. Key stakeholders from frontline staff to executives were targeted to engage, educate, execute, and evaluate the program. The barriers included a lack of leadership support, resources such as equipment, staff, and time, knowledge education deficits by multidisciplinary team members, nonstandardized documentation, nonstandardized sedation and delirium protocols, and lastly safety, pain, and physiological instability. The results of a pilot test exhibited that the program was not only feasible but safe. The bedside tools used to assist in the process were guidelines. The information was used as a reference, but much of the improvements were due to a change in the culture of the unit. The CNS, as an advanced practice nurse, is the expert clinician and change agent that is best qualified to lead in this culture change by role modeling, collaborating, and engaging the team to find sustainable solutions. Ongoing efforts continue as we evaluate our program and expand to a second surgical ICU.

Giving and Receiving Constructive Feedback: The Role of Preceptors in Developing This Skill

Altmiller G, La Salle University, Philadelphia, Pennsylvania

Significance: Constructive feedback is essential for personal and professional growth. Developing skill to provide as well as receive constructive feedback should be part of every clinical nurse specialist's education. It is an integral part of continuous quality improvement, it supports teamwork and collaboration as a communication technique, and it is essential in maintaining patient safety in the clinical environment.

Background/Rationale: The perception of feedback can interfere with professionals giving and receiving it which can have negative effects on patient outcomes. The consequences of not providing feedback are missed opportunities for self-improvement as well as missed opportunities for improved patient care.

Description of Methods: Delivering and receiving feedback effectively are learned skills that need to be developed early on in one's education and be practiced regularly. Faculty, particularly preceptors, can role model this skill and influence the perception of feedback to be viewed as an opportunity so that students can learn to appreciate its value in maintaining patient safety and high quality care in clinical practice. During this presentation, the use of constructive feedback to support the Quality and Safety Education for Nurses (QSEN) competencies for graduate education will be discussed. Challenges to giving and receiving feedback will be identified and participants will learn strategies to deliver constructive feedback effectively.

Outcomes/Findings: Patient safety is supported when processes are in place that allow for feedback and colleagues are comfortable with their skill set to deliver and receive it effectively.

Conclusions/Interpretations: Faculty have the potential to influence the perception of feedback, that is, for it to be viewed and valued as an opportunity for self-improvement, optimal patient safety, and high quality care.

Implications: Preceptors of clinical nurse specialist students are in a unique position to model this skill as a means to maintain patient safety and support quality improvement.

High-Fidelity Simulation Improves Provider Confidence During Advanced Cardiac Life Support Resuscitation Scenarios Even Among Highly Experienced Staff

Zavotsky K, Robert Wood Johnson University Hospital, New Brunswick, New Jersey

Purpose: The purpose of the study was to test the hypothesis that providers undergoing high-fidelity simulation of cardiopulmonary arrest scenarios will express greater confidence.

Significance: Advanced Cardiac Life Support (ACLS) resuscitation requires rapid assessment and intervention. Some skills like patient assessment, quality cardiopulmonary resuscitation, defibrillation, and medication administration require provider confidence to be performed quickly and correctly. It is unclear, however, whether high-fidelity simulation can improve confidence with a multidisciplinary group of providers with high levels of clinical experience.

Design: This was a quantitative, longitudinal, quasi-experimental, prospective cohort.

Methods: The study conducted at an urban level I trauma center from January to October 2011 with a convenience sample of registered nurse (RN) and license practical nurses, nurse practitioners, resident physicians, and physician assistants who agreed to participate in 2/4 high-fidelity simulation (Laerdal 3G) sessions of cardiopulmonary arrest scenarios about 3 months apart. Demographics were recorded. Providers completed a validated pretest and posttest 5-point Likert scale confidence measurement tool before and after each session that ranged from not at all confident (1) to very confident (5) in recognizing signs and symptoms of, appropriately intervening in, and evaluating intervention effectiveness in cardiac and respiratory arrests. Descriptive stats, paired t tests, and analysis of variance were used for data analysis. Sensitivity testing evaluated subjects who completed their second session at 6 months rather than 3 months.

Findings: Sixty-five subjects completed consent, 39 completed 1 session and 23 completed at least 2 sessions. Ninety-two percent were RNs, median clinical experience was 11-15 years, and 56% were from an intensive care unit.

Conclusions: Provider confidence increased significantly with a single session despite the highly experienced sample. There was a trend for further increased confidence with an additional session and the increased confidence was maintained for at least 3 to 6 months given the normal sensitivity analysis.

Implications: This research will provide a basis for future research to determine what impact caregiver confidence has on patient and quality outcomes. The results strongly suggest that utilization of high-fidelity simulation even with experienced nurses in the hospital contributes to increased caregiver confidence and may help to improve outcomes and should be integrated into our education and training practices.

Home Telemental Health: Provides the Right Care, at the Right time, at the Right Place

Harris-Cobbinah DA, Department of Veterans Affairs, New York Harbor Health Care, Bronx, New York; Arden K, Department of Veterans Affairs, New York, New York

Purpose: To provide current information to health clinicians regarding expanded provisions of patient care beyond mental health institutional settings by the use of health informatics, disease management, and Telehealth technologies.

Significance: In 2008, the Veterans Health Administration (VHA) added a subdivision, Telemental Health to their Care Coordination/Home Telehealth department. This subdivision was created to ensure that eligible veterans with a mental health diagnosis have access to a comprehensive and integrated high-quality healthcare continuum that addresses both medical and mental health needs of veterans in urban and rural communities utilizing home monitoring devices and case management. The telemental staff utilizes informatics technologies and telecommunication modalities to augment care provided by both VHA and non-VHA medical and mental health providers. This ensures appropriate continuity of care throughout the course of enrollment.

Design: A chart review of patients enrolled in the program more than 12 months was conducted. The review consisted of the most used mental health diagnosis, the percentage of patients who have a medical diagnosis and mental health diagnosis, the percentage of psychiatric and medical admissions, inpatient admissions, and the length of stay of the inpatient admissions.

Description of Methods: Veterans are referred to the program by self-referral or medical/mental health providers. Accepted veterans are expected to complete daily self-report protocols via telehealth monitors/cell phone systems. If a high-risk behavior or symptom is alerted, a telemental health coordinator will contact the patient for further interventions. These interventions include patient education, provider notification, crisis intervention, referrals to VHA/non-VHA community services.

Findings/Outcomes: There was a significant decrease in hospital admissions and length of stay. Hemoglobin A_1c and blood pressure readings improved. There has also been marked improvement in compliance with clinic appointments and medication regimes.

Conclusions/Interpretations/Implications: Telemental health services facilitate access to care and improve the health of mental health patients with specific intent of providing the right care, in the right place, at the right time. This expanded care improves chronic disease management, patient satisfaction, increase access to services and reduce resource utilization, thus decreasing healthcare costs. VHA health professionals emphasize that home telehealth does not replace traditional homecare but can help veterans understand and manage their medical and mental health conditions at home. Proper management of these chronic conditions can delay the need for institutional care and maintain independence for an extended time.

Hospital-Based Postdischarge Community Case Management by Clinical Nurse Specialists in Rural Texas

Baldwin KM, Black D, Hammond S, Texas Health Resources, Cleburne, Texas

Significance: Chronic disease is a national epidemic. Annual cost for heart disease and stroke is $432 billion; diabetes, $174 billion; and lung disease, $154 billion. Clinical nurse specialists (CNSs) are uniquely qualified to manage chronic diseases across the continuum of care.

Design (Background and Rationale): In 2011, Texas ranked 44th of 50 states for health and was classified as weak to very weak for overall healthcare performance in cardiovascular, diabetes, and respiratory care. Johnson County is a poor, rural county with an average per capita income of 81.3% of the state average. Of the 221 Texas County responding in 2012, Johnson County ranked 126th in health behaviors, access to and quality of clinical care, socioeconomic factors, and physical environment. The county, a designated health professional shortage area, has only 1 hospital, no county health department clinic and only 1 sporadically opened free clinic staffed by volunteers. Over 1 quarter of county residents have no health insurance. One of the ways to minimize preventable hospital or emergency department (ED) visits is through better outpatient disease management. In the last quarter of 2011, we implemented a community case management nurse (CCMN) program to reduce preventable readmissions. We targeted uninsured adults with chronic diseases, who were below the age of 65 and frequently admitted. The CCMN, a CNS with prescriptive authority, works 20 hours per week. She currently monitors at-risk patients via telephone for at least 30 days following discharge.

Findings/Outcomes: The CCMN has used several interventions resulted in continuity of care and improved outpatient disease management. They include helping patients obtain disability certifications, writing prescriptions for needed medications, making mental health referrals, referring to support groups, providing physician referrals, scheduling clinic visits, obtaining diabetic supplies, and appropriately triaging patients to the ED. The results of this program have been decreased morbidity and mortality, decreased hospital admissions, and appropriate referrals for our patients. We have received 1 national nursing award for our program. And, our CEO has approved program expansion.

Conclusions/Interpretations: Telephonic monitoring of at-risk patients at home for 30 days after discharge has decreased readmissions to the ED and hospital. The program has been so successful that our 15-hospital system is now discussing implementing it in other facilities. Because sometimes more than a telephone conversation is needed, we are collaborating with a local university to add real-time virtual visits using android technology. We have also discussed our program with the county EMS physician director. She volunteered the services of county EMS ambulances and paramedics for in-home visits to assess any patients the CCMN deems appropriate for such services. We are also collaborating with the free clinic to increase hours of service there for physical examinations.

Implications for Practice: Our program shows that CNSs with prescriptive authority can impact treatment of rural dwelling patients with chronic disease, both in the hospital and after discharge. The integration of real time virtual visits should improve care and help to build a case for telenursing.

Prewarming of Maternity Patients Undergoing Cesarean Section

Stott S, Banner Health, Phoenix, Arizona

Purpose: The goal of the project was to increase the average patient temperature on admission to both postanesthesia care unit (PACU) and postpartum to meet SCIP criteria of greater than 36[degrees]C through the use of forced air warming.

Significance: The surgical site infection rate at a Level III facility was 2.07% prior to implementing the prewarming protocol. This infection rate dropped to 1.35% after the protocol was implemented.

Background Nationally, 3% of postoperative patients develop surgical site infections. Mild hypothermia suppresses the immune response and increases the incidence of infection. Patient warming and thermal control leads to reduced costs, increased patient satisfaction, and improved outcomes. In the past, warmed cotton blankets have been used to provide comfort and increase body temperature. However, research shows that warmed cotton blankets maintains body heat, but are ineffective at restoring core body temperature. The SCIP benchmark for patient temperature on admission to PACU and Postpartum is 36[degrees]C. Prior to the project the average patient temperature on admission to PACU did not meet this SCIP benchmark. The average patient temperature was 35.8[degrees]C on admission to PACU and 35.9[degrees]C on admission to Postpartum.

Methods: The prewarming protocol calls for the patients to be prewarmed in preoperation for 30 minutes prior to schedule cesarean sections by a forced air warming device.

Outcomes: After implementation of the protocol, the average patient temperature on admission to the PACU was 36.1[degrees]C and 36.3[degrees]C to postpartum. Both of these measures are above the SCIP benchmark and meet the SCIP criteria. Subsequently, the surgical site infection rate dropped to 1.35% after the protocol was implemented.

Conclusions: Prewarming of cesarean patients by forced-air warming increases patient temperatures on admission to the PACU and reduces surgical site infection rates.

Implications: To meet SCIP criteria, decrease infection rates, and improve patient satisfaction, this protocol is being implemented throughout a large multifacility healthcare system as a standard of care for scheduled cesarean section patients.

Hourly Rounding: Improving Patient Satisfaction in the Emergency Department

Ignacio A, Torrance Memorial Medical Center, California; Castillo E, Pacific Hospital of Long Beach, California

Purpose: Improve patient satisfaction in the emergency department (ED) through hourly rounding.

Significance: The ED generates 42% of all hospital admissions nationally. Although this department is an important revenue source for hospitals, it has one of the lowest satisfaction ratings from patients compared with all hospital departments (Press Ganey, 2010). Research indicates that the largest number of complaints about ED care focus around patient treatment, communication, poor staff attitudes, and delay in treatments. These are also causes of patients leaving without being seen. Studies have documented that staff providing information regarding patients' health status and treatments, how well patients are informed about delays, prompt pain control methods, and the attitudes of healthcare providers significantly impact ED patient satisfaction.

Background/Rationale: According to Press Ganey results 2011-2012, the top 3 common themes of patient dissatisfaction in this ED include patients not being updated on the plan of care, pain not adequately addressed or managed, and treatment delays not being explained. Patients who come to the ED are in their most vulnerable time of need. They are scared and anxious, in pain, and uncertain of what might happen next. Research indicates that hourly rounding is one of the best interventions that ED staff can provide to reduce patient anxiety and help control their pain. Explanation of treatment delays will keep them in the ED and not leave without being seen.

Description of Methods: A formalized process of hourly rounding in the ED was developed by the CNS in collaboration with the ED staff, nurse manager, and director. A 1-hour class on patient rounding was provided to the staff during skills fair and multiple in-services were conducted. Documentation of ED rounding was provided by a rounding log which was reviewed by the nurse manager, supervisor, and ED CNS for compliance and accountability. ED technicians rounded during even hours and the ED RNs rounded during odd hours. Pain, explanation of plan of care, and delays in treatments were addressed during roundings.

Outcomes: Patient satisfaction scores in the ED increased 3 months after implementation of hourly rounding. Patient satisfaction scores based on how well the nurses explained patient treatments increased from 80% to 85.8% and reasons for the delays in treatments improved from 64.9% to 73.3%. Patient satisfaction on how well their pain was controlled increased from 75.3% to 82.8%. Patients leaving without being seen were reduced from 4.2% to 3%.

Conclusions: Hourly rounding improved patient satisfaction results and reduced the number of patients who left without being seen in the ED.

Implications: Developing a structured format of hourly rounding, monitoring through the use of rounding log to hardwire the practice, and incorporating it in the ED policy and procedures will improve patient care management and satisfaction.

How to Help Patients Manage Weight: Do You Have a Tool Box of Weight Management Strategies?

Timmerman GM, The University of Texas at Austin, School of Nursing

Purpose: The purpose is to provide CNSs with information about effective weight management strategies that can be shared directly with patients and also with nurses who work with patients who would benefit from these strategies.

Significance: Excess weight is a major problem, impacting the majority of adults. Obesity and weight gain increase the risk for many chronic lifestyle diseases. Interventions that can facilitate weight management, both weight loss and preventing weight gain, can improve overall health outcomes.

Background: Only recently have researchers begun to focus on the influence of the environment on food consumption, yielding possible strategies that can be used for weight management. A calorie deficit is required for weight loss. Although food diaries that track caloric intake can be very effective for those who use them, many individuals are unwilling to put forth that amount of effort. Wansink (2006) proposes that we "reengineer" our food environment to minimize the effort required to reduce calories.

Description: Based on work with participants in the Mindful Restaurant Eating intervention, there were lessons learned about the importance of presenting participants with a variety of strategies that they could choose related to weight management. Many evidence-based weight management strategies are available such as eating mindfully, eating vegetables first, eating fruit before snacking, using replacement meals, eating a hot breakfast, using 10-inch plates, making tempting foods inconvenient to access, monitoring hunger and fullness cues, and avoiding sugar filled drinks. Participants were taught how to set their own goals and individualize strategies to deal with their barriers.

Outcome: Different weight management strategies were acceptable to some but not others, supporting the idea of partnering with patients and facilitating individuals in choosing strategies that best fit their lifestyle. Individualized weekly goal setting was perceived as one of the most useful strategies.

Conclusion: By empowering patients to choose strategies that impact weight management, some of which could easily be implemented, nurses may be able to encourage success for those patients who are reluctant to make substantive changes. Even small caloric reductions over time could prevent additional weight gain or possibly weight loss.

Implications: Clinical nurse specialists need to help nurses develop an efficient way to provide a tool box full of evidence-based, specific weight management strategies that patients can choose to try. Providing more guidance than just eat less and avoid fatty foods is needed to improve patient outcomes. (Wansink B. Mindless Eating. New York: Bantum Books; 2006.) Mindful Restaurant Eating intervention was funded by the North and Central Texas Clinical and Translational Science Initiative (5UL1RR024982-03).

Idea to Innovation: Understanding Clinical Nurse Specialist Practices Through a Tracking Tool

Colwill JP, Albert NM, O'Rourke CP, Cleveland Clinic, Ohio

Purpose: The purposes of this study were to quantify how CNSs spend time (work roles), determine if work roles were associated with personal characteristics and goals and examine associations of time spent in work roles and in quality initiatives over time.

Significance: Clinical nurse specialist work roles are broad in scope and difficult to quantify. Healthcare leaders may not understand the impact CNSs have on performance measure improvement over time. Clinical nurse specialists should use quantifiable methods to demonstrate work roles and their impact on clients, nursing practice and organizations and systems.

Design: This prospective, single-center, correlational study used a convenience sample, investigator-developed Role Tracker Tool (software) and a 1-page survey to document CNS characteristics, work roles, quality initiatives (QIs), and unit-based quality scores at baseline and monthly for 5 months.

Methods: Clinical nurse specialist subjects recorded their perceptions of current work roles and QI priorities every month, and minutes spent in each role every month and transmitted data electronically to the principal investigator. Descriptive statistics were used to summarize CNS characteristics and Kruskal-Wallis rank sum test and Spearman's rank correlational statistics were used to measure associations between characteristics and work roles. Tests for differences of average time spent in a role were completed using a Welch 2-sample t test and analysis of variance. Hierarchical linear models were used to determine if relationships existed over time between work roles, priority ranking of work roles and nursing characteristics.

Findings: Fourteen CNSs participated; mean age was 43.15 (SD, 10.11) years and mean time as a CNS was 5.57 (SD, 7.87) years. For 6 work roles, CNSs ranked quality as the most important, followed by clinical work and research work ranked 4 of 6 options. Mean (SD) time spent over the 5 month period was highest for clinical work (2251 minutes/month/CNS +/- 1216 minutes) and lowest for professional self-development (550 minutes/month/CNS +/- 500 minutes). Amount of time spent in specific roles varied by specialty, certification status, years as a CNS, and other characteristics, even after controlling characteristics that were significantly associated with work roles. For all work roles but quality, CNS role priority rankings were associated with time spent (all P <= .02); however clinical and consulting roles were not based on CNS priorities. Clinical nurse specialists' baseline work role priority rankings were not associated with most characteristics. Of 9 QI focuses, mean (SD) time spent was highest for heart failure, even though only 2 CNSs were involved (2227 minutes/month/CNS) followed by venous thromboembolism (1215 minutes/month/CNS) and pressure ulcer (460.4 minutes/month/CNS). Time spent on QIs was associated with QI outcomes for 6 quality focuses (all P <= .03).

Conclusions: Clinical nurse specialist work role priorities and QI focuses varied over time. Amount of time spent in work roles were associated with CNS characteristics.

Implications for Practice: Clinical nurse specialist work can be captured and communicated to enhance the understanding of their unique role and contributions in the healthcare matrix.

The Impact of a Clinical Nurse Specialist Initiative to Change Practice Through a New Paradigm for Competency Assessment

Marzlin KM, Aultman Hospital, Uniontown, Ohio

Purpose: The purpose was to assess the impact of a new approach to competency on the adherence to evidence-based cardiac monitoring practices; and to evaluate the impact on nurse confidence and engagement in these practices.

Significance: Cardiac monitoring contributes to patient safety by identifying conduction abnormalities, silent ischemia, and prolonged QTinterval. Evidence demonstrates patient outcomes are improved through accurate cardiac monitoring. The historical approach to competency assessment in nursing has been the clinical skills checklist. This approach does not assess the translation of the science behind the practice, or the required critical thinking and decision making skills. Therefore, a new paradigm is needed.

Design: The following components were integrated into the new competency paradigm (a) professional portfolio, (b) self-assessment of adherence to practice expectations, (c) direct observation of clinical practice, (d) review of unit based quality improvement data, (e) case studies, and (f) nurse choice of reflective exemplar, peer review statement, evidence-based article review, or achievement of critical care certification. Evidence-based cardiac monitoring indicators were assessed preintervention and postintervention. Nurse perceptions were assessed after intervention.

Methods: Monitoring indicators were assessed preintervention and postintervention: (a) lead placement, (b) ST segment alarms, (c) documentation of type of BBB, (d) measurement of QTc interval, (e) documentation/reporting of clinically significant arrhythmias. Pre and post percents were compared using 2-sided Pearson [chi]² tests, with the exception that Fisher exact test was used when the expected cell number was less than 5. A postintervention survey was done to assess the achievement of nurse satisfaction and engagement. Analysis of the nurse survey data included the frequency distributions, calculation of medians and interquartile ranges for each question.

Outcomes: The improvement for the accuracy for V lead placement was 27.1%; P <= .001. The improvement for the accuracy for limb lead placement was 20.41%; P = .004. Accurate identification of type of bundle branch block showed an improvement of 52.5%; P = .003. The accurate assessment to QTc interval showed an improvement of 22.45%; P <= .001. The posting of clinically significant arrhythmias showed an improvement of 38.5%; P = .005. Additionally, the nurse survey showed agreement with increased confidence regarding competency (85%) as well as increased engagement in the cardiac monitoring process (77%).

Interpretation: Improvement in several evidence-based cardiac monitoring indicators showed statistical significance with trends towards improvement in the other indicators that did not meet statistical significance. This change in clinical practice occurred in conjunction with an increase in nurse engagement and satisfaction with a new paradigm in competency assessment.

Implications: This project demonstrates that a comprehensive competency assessment program integrating the assessment of real time clinical practice has the potential to improve adherence to evidence-based standards of practice. It also brings to light the scope of knowledge and skill required for competence at the point of care. The results of the nurse survey demonstrate that the majority of nurses welcome the acknowledgement of the complexity of their practice and embrace a process that calls for accountable care.

Impact of Day of Surgery Activity on Meeting Criteria for Discharge in Knee Replacement Patients

Ryzner D, Northwest Community Hospital, Arlington Heights, Illinois; Ogilvie MA, Northwest Community Hospital, Rolling Meadows, Illinois

Purpose: Explore whether day of surgery (DOS) activity results in total knee replacement (TKR) patients being able to meet criteria for discharge from the hospital sooner than patients who remained in bed on DOS and do not have any activity.

Objectives: (1) Name 2 benefits of early mobilization after TKR surgery and (2) describe 2 criteria used to determine readiness for discharge after TKR surgery.

Significance: DOS activity for TKR patients has been shown to increase muscle strength, decrease risk of postoperative complications, increase range of motion, and improve length of stay (LOS).

Background: Total knee replacement surgery is a common, successful intervention that greatly improves function, relieves pain, and improves quality of life. Early rehabilitation after surgery helps increase joint range of motion and muscle strength, enabling patients to achieve maximum benefit from TKR. Risk of complications like deep vein thrombosis, pulmonary embolism, and pulmonary infection are decreased when patients are mobilized early. A randomized controlled trial (Labraca, Castro-Sanchez, Mataran-Penarrocha et al, 2011) demonstrated that early mobilization decreased hospital LOS and reduced the number of rehabilitation sessions needed to achieve autonomy with normal gait and balance for patients. Morris, Benetti, Marro, and Rosenthal (2010) implemented Clinical Practice Guidelines (CPG) that included dangling the patient on DOS. Collaboration among care providers for CPG implementation showed enhanced benefits of early activity and reduced LOS.

Hypothesis: If TKR patients have activity such as dangle or out of bed on DOS, then they will be ready for discharge sooner than patients who remain in bed on DOS.

Description of Methods: Nonexperimental correlational, retrospective design. Institutional review board approval obtained. Researchers used a convenience sample of 1 orthopedic surgeon's TKR patients. Patients all receive continuous femoral nerve block. Group 1 (n = 60) consisted of patients before the enhancement of physical therapy (PT) evaluation and treatment on DOS. Group 1 patient activity on DOS was performed only by nursing staff. Group 2 patients (n = 87) received PT evaluation and treatment on DOS. Literature review was conducted. Criteria from a PT perspective were established to indicate readiness for hospital discharge. Two discharge criteria of 'needing no to minimal assistance' and 'ambulate 50 feet' were selected. Collaboration between PT, nursing, and surgeons for the DOS activity initiative was vital.

Findings/Outcomes: Patients with DOS activity met discharge criteria sooner than patients who remained in bed (statistically significant P = .003). Though not statistically significant, a secondary finding showed lower mean for last pain score documented at discharge for patients who had DOS activity versus patients who remained in bed (mean, 1.93 vs 2.41, P = .095).

Conclusions/Interpretations: Hypothesis is supported. Patients with any activity on DOS met criteria for discharge sooner than those who remained in bed. A limitation is that 1 surgeon's patients were studied to eliminate variables in surgical technique and differences in pain management. This small study is not generalizable.

Implications: Further research to examine most efficient use of nursing and therapy resources for optimal benefit of TKR patients. Research on other multimodal pain management techniques and time to meet discharge criteria could be considered.

Implementation of the Humpty Dumpty Falls Scale: A Quality Improvement Project

Close JF, Palomar Health, San Diego, California

Purpose/Objectives: To implement a pediatric-specific fall risk screening tool to be used for all pediatric patients (14 years and younger) in the Palomar Health System.

Significance: Patient safety is a priority in healthcare. The Joint Commission (TJC) and the Institute of Medicine have placed a great emphasis on patient safety and decreasing adverse events during hospitalization. The hospital environment places patients at increased risk for falls related to physiologic factors, medications and the use of equipment. TJC recommends that hospitals have a method to identify children at risk for harm from falls as well as a screening process to determine which children are at risk. Efforts should be made to assess and protect this population.

Background: The Morse Fall Risk Screening tool was being used for all patients at Palomar Health. A group led by the geriatric CNS designated to manage fall prevention and CNSs from the emergency departments (EDs), birth center and pediatric unit met with staff nurses to look at the health system's process for identifying pediatric patients at risk for falling. Falls data for our system did not show any pediatric patient falls. Our team suspected that pediatric falls were not being reported, which is consistent with the literature.

Description: The Humpty Dumpty Falls Scale (HDFS) is a screening tool designed by an interdisciplinary team of nurses from Miami Children's Hospital in Miami, Florida. There are 2 scales, inpatient and outpatient. The tool is broken down into age, gender, diagnosis, cognitive impairment, environmental factors, response to surgery/sedation/anesthesia and medication usage. A score is given in each of those sections. A total score of 12 or above is considered at high-risk and warrants implementing a protocol to protect the patient. The EDs, birth centers, NICUs, and pediatric unit all planned to implement the inpatient tool. Pediatric and NICU nurses were given a pretest regarding pediatric falls, and then education was provided about falls and the HDFS. After a posttest was given, the HDFS tool was piloted. Following education in both the EDs, the HDFS was implemented.

Outcomes: The HDFS was found to be an innovative tool for improvement in clinical practice. It has also heightened awareness of the need for fall risk screening in the pediatric population.

Interpretation/Conclusion: All patients at Palomar Health are screened for fall risk using an age appropriate tool. Implementation of the HDFS tool has led to the appropriate screening for pediatric patients, which in turn improves patient safety.

Implications for Practice: The HDFS tool has allowed our nurses to screen this population and implement safety precautions to protect our patients from falls. All patients 14 years or younger are screened in the ED using the HDFS. Those at risk are identified to allow heightened awareness about safety precautions.

Implementing a Mobility Program on an Inpatient Medicine Unit

Wood W, Tschannen D, Grunawalt J, University of Michigan Hospitals and Health Centers, Ann Arbor

Purpose/Objectives: To decrease the negative effects of bed rest and improve patient outcomes through implementing a mobility program on a medical inpatient unit.

Significance: Research has shown that immobility or bed rest has negative effects on the human body, including muscle weakness, atrophy, pneumonias, constipation, and pressure ulcer formation. (1) Cardiorespiratory and muscular decline has also been found in patients with short-term hospitalizations who presented with mild disease severity. (2) Although the adverse effects associated with bed rest/immobility and the benefits of ambulation/mobility have been reported, patients still spend a large amount of their hospital stay in the bed or chair. Current evidence related to implementation of mobility programs has primarily focused on patients in intensive care units, with the exception of 1 study conducted by Markey D. and Brown R. (3) This evidence-based translation project describes how an early mobility project impacted patient outcomes on a general medicine unit.

Design: This project utilized a descriptive design. Data were entered and analyzed using the Statistical Package for Social Sciences (Chicago, Illinois) version 17.0 for Windows software. Computations for frequencies, percentages, means, ranges, and standard deviations were completed. Analyses focused on determining if increasing mobility of adult patients admitted on a medicine unit decreased the unit fall rates, incidence of pressure ulcers, length of stay, and readmission rates.

Methods: The interdisciplinary team consisting of nursing staff, nurse aides, unit physical and occupational therapists, leadership, and a school of nursing representative, developed mobility guidelines and interventions for the program. Patients who were ambulatory (eg, tier 2) were assisted to ambulate 3 times a day, while nonambulatory patients (tier 1) participated in active or passive ROM 3 times a day. The unit manager assigned 2 nurse aides to function as "mobility aides." Their responsibilities were to perform activities with patients after receiving direction from the patients RN and unit therapists. Patients and their family members were given a handout describing the program and families were encouraged to assist.

Findings: A total of 534 patients were admitted to the unit during the project timeframe (3 months). Of those patients, 96% (n = 521) of them participated in the mobility program during their stay. Approximately 69% (n = 373) were identified as at risk for falls. In terms of tier levels: 80% ambulated independently or with assistance (tier 2), 11% received ROM (tier 2), and 5% varied between the tiers (.eg participated in tiers 1 and 2). In terms of mobility compliance to the protocol, 58% of patients participated in mobility exercises at least 3 times each day during their stay, while 88% of the patients participated in at least 2 mobility exercises each day. In comparing patient outcome data, 3 months prior to implementation to 3 months postimplementation, there has been a decrease in readmission rates and falls. Pressure ulcer incidence and length of stay have remained relatively consistent.

Conclusions/Implications for Practice: The mobility program has shown positive outcomes; decreased unplanned readmissions, falls, and increasing patients' activity during their hospital stay. This program can be replicated on other medicine units.

Implementing a Pediatric Early Warning System in a Community Hospital Setting

Somberg CM, Northwestern Lake Forest Hospital, Deerfield, Illinois

Purpose/Objectives: Purpose is to influence the phenomena of patient safety in an inpatient pediatric community hospital setting. Objective was to determine if there was a difference in the number of pediatric code blue calls and emergency intubations between preimplementation and postimplementation of Pediatric Early Warning System (PEWS) and a Pediatric Rapid Response Team.

Significance: A Pediatric Rapid Response Team and PEWS provide a tool to identify pediatric patients who may be at risk for deteriorating condition and arrest. The system quickly provides the resources to assess, stabilize, and facilitate transfer of the patient to a higher level of care. The CNS can lead development of Pediatric Rapid Response Team and PEWS implementation, within the limited resources of a community hospital setting, influencing patient outcomes by decreasing occurrence of pediatric code blue calls/emergency intubations providing early recognition of physiological deterioration.

Design: The evidence has shown a decrease in the number of code blues of hospitalized children after initiating Pediatric Rapid Response Teams and PEWS, impacting patient safety outcomes. PEWS scoring was developed using the literature, along with the regional children's hospital protocols, tailoring the tool to meet a community hospital's requirements. Relationship-based Care model (Creative Health Care Management, 2004) provided nurses with a framework for the change in practice. The Promoting Action on Research Implementation in Health Services (PARIHS) (Rycroft-Malone, 2004) was used to guide the implementation process.

Description of Methods: Developing a Rapid Response Team and implementing PEWS was targeted for an inpatient pediatric department within a community hospital. Specific PEWS scorecard and an action plan were developed to reflect a community hospital's patient population and resources. The PEWS scoring tool was built into the electronic medical record. Nurses document PEWS scores on all patients within 1 hour of vital signs and assessments. Nurses follow standardized PEWS scoring and action algorithms. PEWS scores trigger specific nursing interventions.

Findings/Outcomes: Outcomes consist of no emergency intubation or code blue calls since inception of the pediatric rapid response team and PEWS scorecard on April 15, 2012. A rapid response team monitoring tool tracks all rapid response team calls. PEWS scores serve as a trending tool for patient improvement and deterioration.

Conclusions/Interpretations: Overall, the implementation of PEWS and Pediatric Rapid Response Team influenced code blue and emergency intubation rates impacting patient safety.

Implications: The implementation of this practice change had positive effects on patients, nurses, and the organization. The CNS influences direct patient care outcomes, nursing to intervene with a standardized evidence-based protocol and the system by impacting the patient safety culture within the institution.

Implementing a Progressive Mobility Program in the Surgical Intensive Care Unit

Fitzpatrick ER, Thomas Jefferson University Hospital, Glenside, Pennsylvania

Purpose: To implement a new evidence-based standard of care for progressive mobility for surgical intensive care patients.

Significance: Immobility, deconditioning, and weakness are common in critically ill patients and contribute to prolonged hospitalization and complications. Implementing a progressive mobility program in the earliest days of hospitalization results in better patient outcomes and shorter hospital stays. This practice will optimize recovery in intubated and nonintubated surgical ICU patients through increased physical activity and range of motion exercises begun immediately postoperatively.

Design: Based on the current literature implementing a progressive mobility program has the promise of improving patient outcomes and we sought to provide our patients similar effects. Among patients (on and off ventilators) in early and progressive mobility programs, 83% survived to hospital discharge with a medical ambulation distance of 200 ft. with adverse effects occurring in less than 1% (Bailey et al, 2007). There were fewer ventilator days, shorter hospital and unit length of stay, and fewer immobility-related complications (Thomsen, 2008). Survival to discharge was higher and capacity for ambulation and strengthening exercises was greater (Thomsen, 2008). Return to independent functional status was faster (Schweikert et al, 2009).

Methods: Sample: Patients older than 18 years admitted to the surgical intensive care unit and possessing baseline functional independence. Patients excluded are those with known/suspected unstable spine, an open abdominal wall, hemodynamically unstable, or those with an unstable airway (airway edema, difficult intubation).

Methods: To determine a patient's appropriateness for early and progressive mobility the nursing staff performed daily assessments using a checklist which defines criteria for patients' involvement in/progression through increased levels of activity. Activity performed (or discontinued) was also documented. Data were collected for surgical patients housed in units with 25-bed total capacity. Average daily census was approximately 18 patients during this time. Occasionally, medical patients are housed on the unit. These patients were not included in data collection. Data were collected relative to effective participation in the program as well as to length of stay data. Additional data review is currently being performed on the rates of ventilator-associated pneumonia as well as pressure ulcer rates before and after the implementation of the program.

Findings: To be identified.

Conclusions: To be identified.

Implications: The American Association of Critical-Care Nurses has identified the prevention of complications in critically ill patients as an important research priority for our profession. Complications after surgery and trauma have negative implications for the outcomes of critically ill patients. Pneumonia, deep vein thrombosis and even pressure ulcers can threaten the life of our patients, and at the very least can prolong the ICU and hospital lengths of stay. It is imperative that critical care nurses develop and use the evidence to enable them to institute strategies for preventing complications in this population. Nursing assessment and implementation of progressive mobility in the critically ill surgical patient will have an impact on the occurrence of complications in the critically ill surgical patient.

Improving Care for Older Adults Through Education of Nurses as Adult Gerontology Clinical Nurse Specialists

Murray DM, Curry-Lourenco K, Fowler C, Sharp P, Old Dominion University, Norfolk, Virginia

Significance: This presentation will describe the transition from a Nurse Educator program to an Adult Gerontology Clinical Nurse Specialist (CNS)/Educator Program that prepares graduate nurses to address the healthcare needs of underserved geriatric populations. The goal of the transition is to increase the number and distribution of culturally diverse CNS providers from minority and disadvantaged backgrounds. The CNS graduates will be prepared to serve as educators, researchers, expert clinicians, collaborators, and consultants providing patient-centered care to improve health outcomes for older adults. The program is delivered through Web-based didactic courses, clinical practicum experiences, standardized patient scenarios, interprofessional care conferences, and a teaching internship.

Background: The specific goals of this transition were (1) to recruit, retain, and graduate nurses from underrepresented minorities and underserved regions of Virginia as Adult Gerontology CNS/Educators; (2) to educate nurses to function in the Adult Gerontology CNS/Educator role as an interdisciplinary team member in acute, long-term and community-based care settings that provide healthcare services for older adults; and (3) to enhance the capability of the Adult Gerontology CNS/Educator to provide instruction on issues of aging and care of older persons using knowledge of adult learning theory and evidence-based teaching/learning best practices.

Methods: The courses were developed and implemented by the CNS curriculum committee consisting of the project director, CNS program and practicum coordinators, nurse educator coordinator, and gerontology content coordinator. An array of geriatric healthcare professionals from the HRSA-funded Virginia Geriatric Education Center will serve as consultants.

Outcomes: Courses began in the fall semester of 2012. There are 13 part-time students enrolled for 2012-2013. Ten students are completing the master of science curriculum. Three students hold a master of science and are completing the Adult-Gerontology CNS/Educator post-master's degree certificate curriculum.

Conclusions: The project focuses on educating nurses who will be able to practice as Adult Gerontology CNS/Educators within rural and underserved populations. Second, students recruited to participate in this distance program will come from many of the rural areas of Virginia considered Health Professional Shortage Areas. This access to quality distance education is aimed at increasing the likelihood that graduates will remain in their communities and contribute to efforts to enhance healthcare services and promote quality outcomes for older adults.

Implications: This program will prepare the graduate to assume a teaching role in clinical or academic settings, thus fulfilling a critical need for nurses with knowledge of gerontology and formal graduate education in teaching/learning methods who are able to serve in faculty positions.

Improving Care One SCIP at a Time: Overcoming Barriers to Postoperative Urinary Catheter Removal in Thoracic Surgery Patients With Epidural Infusions

Craig S, University of Virginia Health System, Barboursville; Nigro K, and Morton S, UVA Health System, Charlottesville

Purpose: Achieve improved adherence to postoperative urinary catheter removal in thoracic surgery patients with epidural infusions.

Background and Significance: Epidural catheter placement is common following open thoracic surgeries. Traditionally, urinary catheters are left in place for the duration of epidural use to prevent postoperative urinary retention (POUR). However, the risk of urinary tract infection (UTI) increases each day the urinary catheter remains in place. A literature review identified the risk of POUR as low following urinary catheter removal and continued epidural use. When urinary retention is present the incidence of UTI with an in-out catheterization is less than the risk of UTI with an indwelling catheter. The Joint Commission Surgical Care Improvement Project (SCIP) monitors several surgical core measures including adherence to postoperative urinary catheter removal no later than day 2 unless documented medical necessity. The sample thoracic surgery nursing unit did not consistently meet SCIP measures related to urinary catheter removal by day 2. An interdisciplinary group identified thoracic patients with epidurals as a significant portion of the failures to meet SCIP. Nursing barriers to adherence included nurses were not convinced that this was safe practice for patients, nurses and providers were unfamiliar with the institution's bladder scan algorithm to avoid catheter reinsertion, increased time and labor associated with early removal, and catheters were removed early but nursing documentation was incomplete in the new electronic medical record system.

Methods: A workgroup analyzed nursing barriers to adherence to postoperative urinary catheter removal. The workgroup created a comprehensive education module for unit nursing staff. The module reviewed the literature related to epidurals and urinary catheter removal, SCIP and the significance of early urinary catheter removal, interventions to prevent urinary catheter reinsertion, the institution's bladder scan algorithm, and correct nursing documentation in the electronic medical record. The ten minute module was presented one-on-one in a standardized method by the core RN workgroup to each member of the unit nursing staff over a 1-month period. Nurses were given a short quiz and required to demonstrate documentation at the end of the teaching session to highlight major points. Chart reviews followed the education intervention to monitor adherence to urinary catheter removal day 2 and remediation was provided to staff.

Outcomes: Nursing staff resistance towards early postoperative urinary catheter removal in epidural patients has decreased. Adherence to early postoperative urinary catheter removal and utilization of the institution's bladder scan algorithm has increased. Device utilization, UTI rates, SCIP data show a downward trend since completing the education module for all thoracic surgery postoperative nursing staff.

Conclusions and Implications for Practice: Postoperative day 2 urinary catheter removal in thoracic surgery patients with epidural infusions represented a significant practice and culture change on the postoperative thoracic surgery nursing unit. Unit level needs assessment and analysis is a crucial step in implementing national and institutional practice changes at the unit or patient population-specific level.

Improving Neurologic Function After Cardiac Arrest Through Therapeutic Hypothermia

Ignacio A, Torrance Memorial Medical Center, California; Castillo E, Pacific Hospital of Long Beach, California

Purpose: Improve outcomes in patients after resuscitation from out-of-hospital cardiac arrest.

Significance: Post-cardiac arrest patients have a high mortality rate and poor neurologic outcomes in spite of standard postresuscitation care and intensive critical care monitoring. Of 164 000 cardiac arrests occurring in the United States annually, 65% to 95% dies. Those who survive have suffered adverse health outcomes. The post-cardiac arrest patient often has limited physical abilities and physiologic instability.

Background/Rationale: The American Heart Association recommends initiation of therapeutic hypothermia to patients who remain comatose after resuscitation from sudden witnessed out-of-hospital cardiac arrest. Therapeutic hypothermia is an intervention that cools the postarrest patient to a temperature of 32[degrees]C to 34[degrees]C with iced saline or other surface cooling measures after the return of spontaneous circulation and maintained at that temperature for 18-24 hours. Research has shown that patients in the hypothermia group were more likely to survive to hospital discharge compared with standard postresuscitation care. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality following cardiac arrest.

Methods: A policy and protocol was developed by the CNS in collaboration with the ED and ICU nursing staff, ED physicians, respiratory therapy, physical therapy, pharmacy, and clinical informatics, which outlined the approach for instituting immediate hypothermia in patients remaining comatose following out-of-hospital cardiac arrest. The goal was to start therapeutic hypothermia within 6 hours after return of spontaneous circulation and to keep the patient's temperature at 33[degrees]C for a period of 18 to 24 hours. Staff was educated about the protocol, and a therapeutic hypothermia kit was provided to the ED and ICU which contain the protocol and supplies to initiate hypothermia.

Outcomes: Findings were based on mortality rate and neurologic outcomes. Modified Rankin Scale (MRS) was used to measure neurologic outcomes. An MRS score of 2 or lower indicates a good functional outcome. There were 17 patients who met the criteria for therapeutic hypothermia since the program started in 2011. Eight patients survived with good neurologic outcomes (MRS score of 1-2), 7 expired and 2 were discharged with neurologic deficit (MRS score of 3 and above). Results showed that there was a 47% survival rate among patients treated with therapeutic hypothermia with good neurologic function. This supports the findings revealed by previous studies which showed a 47% to 49% survival rate among out-of-hospital cardiac arrest patients treated with therapeutic hypothermia.

Conclusions: Results suggest therapeutic hypothermia decreases mortality rate and improves neurologic outcomes.

Implications for Practice: Based on the evidence in the literature and the results of this project, therapeutic hypothermia should be incorporated in the care of patients after cardiac arrest.

Improving Outcomes in the Out-of-Hospital Cardiac Arrest Patients: A Clinical Nurse Specialist-Led Evidence-Based Initiative

Webner CL, Marzlin K, Aultman Hospital, North Canton, Ohio

Purpose: The purpose was to evaluate the impact of a real time initiative on the outcomes of the out-of-hospital cardiac arrest (OOHCA) population undergoing therapeutic hypothermia (TH).

Significance: OOHCA affects 236 000 to 325 000 people in the United States annually. Lack of knowledge, experience, personnel, resources, and infrastructure are barriers to implementing effective hospital-based care. Therapeutic hypothermia in the nonresponsive survivor of cardiac arrest improves outcomes. Critical care nurses are faced with many challenges in the care of this vulnerable population. The clinical nurse specialist (CNS) is in a leadership position to influence the processes essential for improved outcomes.

Design: The following interventions were implemented (a) development of a CNS on call system to provide nursing support, (b) identification of a core group of TH nurses utilizing specific criteria for selection, (c) implementation of new staffing ratios, (d) collaboration with Heart Lab to improve patient transitions, (e) development of a "tool kit" to provide resources for point of care nurses, (f) completion of comprehensive core team education and competency, (g) utilization of Gibbs Reflective Cycling for core team reflections on each exposure to this cohort, (h) utilization of real time core team debriefing, and (i) establishment of monthly steering committee and quarterly core team meetings.

Methods: Baseline data were collected on all OOHCA patients admitted to CCU and treated with TH from January 2010 through October 2010. All patients admitted to CCU receiving TH post-OOHCA between the dates of January 1, 2011, to July 31, 2012, served as the intervention group. Key criteria were assessed preintervention and postintervention: (a) time from initiation to achievement of target temperature, (b) time from initiation of rewarming to achievement of normothermia, (c) maintenance of normothermia for 48 hours after protocol, (d) evidence of prognostication free period for 72 hours after protocol, (e) documentation of cognitive function at discharge via the Glasgow-Pittsburgh Cerebral Performance Categories. Statistical comparisons between the preintervention group and the postintervention group were carried out using the Fisher exact tests for the percent comparisons.

Outcomes: Key results included improved rewarming times from 305 minutes (control) to 824 minutes (intervention). Documentation of an appropriate prognostication free period improved from 33.3% (control) to 100% (intervention). The absence of fever for 48 hours after achievement of normothermia improved from 33.3% (control) to 75% (intervention). Cerebral Performance Categories at discharge showed a 25% favorable outcome in the control group and a 54% favorable outcome in the intervention group.

Interpretation: Improvement in the key structures and processes of TH resulted in an improvement in patient outcomes, including the number of patients with meaningful survival.

Implications: The project results demonstrate that a CNS-led initiative for a specialized patient population can be effective in improving evidence-based practice and impacting patient outcomes. The project impacted all 3 spheres of CNS practice. A low-volume, high-risk population provided the perfect backdrop to measure CNS effectiveness. This model of CNS-led care can be applied to other patient populations with complex nursing, patient, and system needs.

Incorporating Evidence Into Practice Policies and Procedures

Hodge NS, Madigan Army Medical Center, Lakewood, Washington

Purpose: To devise and implement a systematic approach to ensure new and updated nursing care policies/procedures/guidelines incorporate the strongest level of evidence.

Significance: Evidence-based practice is the use of the current "best" evidence in conjunction with clinical expertise and patient values to guide healthcare decisions. Evidence comes from research findings, as well as case reports and expert opinion. In the past, most nurses used their educational knowledge along with intelligent guesswork, hunches, and experience to determine the best course of action in any given patient scenario. Sources for nursing policies originated in these same traditional practices rather than sound evidence (Pape, 2003). Highly regarded clinical studies conducted over the past few decades have produced research knowledge that can/should be used to guide nursing practice.

Design (Background/Rationale): When developing or updating nursing care policies/procedures/guidelines, relevant evidence is evaluated for quality and strength and integrated into the policy. Evidence-based practice guidelines have become critical components of nursing and healthcare. Evidence-based practice empowers nurses to provide high-quality care that improves patient outcomes and minimizes healthcare costs.

Description of Methods: Nurse Scientists and clinical nurse specialists are utilized to perform or assist with assembling, critiquing/grading, and synthesizing relevant research and related literature. The AGREE Instrument is used as the framework for assessing the overall quality of the clinical practice guideline under development. The Army Nurse Corps-adopted Evidence Evaluation Tool and the Madigan Army Medical Center Nursing Evidence and Synthesis Tool are used for determining evidence strength and quality.

Findings/Outcomes: Twelve patient care procedure policies undergoing revision have had evidence incorporated into the policy. Five new policies have been developed with evidence from the literature that has been critiqued and graded for strength and quality.

Conclusions/Interpretations: Integrating this heavily scrutinized evidence into policies promotes nurses to reconsider outdated or unscientific practices and adopt current, research-based ones instead.

Implications: Evidence-based practice guidelines provide valid and tested justification for many patient care treatments performed by nurses. Incorporating evidence into practice guidelines/policy increases the speed of knowledge dissemination and the process of implementing research in practice settings. Incorporating evidence into practice guidelines promotes high-quality, cost-effective care.

Incorporating the Teach-Back Method Into Nursing Practice to Prevent 30-Day Readmissions: An Innovative Collaboration Led by a Clinical Nurse Specialist

Santiago-Rotchford L, Bayhealth, Camden, Delaware

Purpose: In order to change practice by incorporating the utilization of the teach-back method, planning needed to include multiple disciplines who educate patients. These changes required a redesign of the electronic medical record. Insufficient level of understanding of education provided during hospital stay has been recognized as 1 cause of readmission within 30 days of discharge.

Significance: Healthcare organizations are now faced with reduction in reimbursements from the Centers for Medicare & Medicaid Services for cost of services for patients who are readmitted within 30 days of discharge from acute care facilities. Educating patients is crucial to preparing patients to care for themselves and to recognize the resources that are available for health promotion outside of the hospital setting. Teach-back is a method of educating patients who has been well documented in the literature that enables the patient to communicate to their healthcare provider their level of understanding.

Design (Background/Rationale): A multidisciplinary team was created in order to identify opportunities for improvement and to define an organizational method of educating patients. The primary intention was to educate, reassess, and reeducate patients as needed based on reassessments of level of understanding education provided.

Description of Methods: Monthly meetings were organized and led by a CNS in order to design changes to the electronic medical record to incorporate the teach-back method, identify tools to inform patients, and to develop an educational plan that included changes in how nursing, respiratory therapists, and pharmacists educate patients and assess their level of understanding.

Findings/Outcomes: Patient education could be customized based on the individual patient needs using the teach-back method. Education about medications focused on newly prescribed medications with the assumption that patients are well versed on all previously prescribed medications.

Conclusions/Interpretations: Not all patients can participate in teach back. Educational needs for patients are often not addressed in hand off communication. Patients with limited English Proficiency are often not provided with materials congruent with their preferred method of learning. Families and caregivers should be included when attempting to educate patients with limited cognitive abilities or motivation. They need to be made aware of the other resources that are available in order to prevent readmissions within 30 days.

Implications for Practice: Future research will involve the effect incorporation of teach-back has on preventing of readmissions. Primary healthcare providers such as physicians, physician assistants, and advanced practice nurses can utilize this method as fellow members of the multidisciplinary team and promoting healthy habits that patients can learn and continue to use after discharge.

Increase in Patient Satisfaction With Medication Scores From a Clinical Nurse Specialist-Led Pilot

Schedler SR, Shawnee Mission Medical Center, Kansas

Purpose: (1) Develop a hospital-wide process for RN education of medications. (2) Provide a useful tool for RN staff to provide effective patient education for new medications. (3) Increase hospital-wide scores for patient satisfaction with medications.

Significance: The CNS-led pilot demonstrates the ability of the CNS to lead innovations for healthcare change. The ability of the CNS to impact hospital patient satisfaction scores is significant as payment to hospitals is partially dependent on patient satisfaction scores.

Background: A 450-bed community hospital experienced patient satisfaction with medication scores in the 60th percentile. The Acute Care CNS was asked to lead the multidisciplinary patient education team in a 4 week unit-based pilot on the 32-bed progressive care unit (PCU).

Description of Methods: The CNS led the multidisciplinary patient education team in the development of 16 medication education cards. Each card listed the name of the medication, purpose for taking, and possible adverse effects. The 4x5 cards were placed in a file box next to the medication dispensing system. Prior to beginning the pilot the RN staff was instructed daily for 10 days by the CNS through safety huddle, posted flyers, and one-on-one review. The staff was instructed to obtain a medication card after retrieving the medication from the dispensing system. The staff was instructed to review the information on the card with the patient and give the medication card to the patient with the first dose of the new medication. The patient satisfaction with medication scores for the PCU were followed weekly 4 weeks. At the end of the 4-week pilot, the RN staff was asked to complete a brief evaluation form developed by the CNS.

Outcomes: The PCU experienced an 18% increase in patient satisfaction with medication scores following the 4-week pilot. The postpilot evaluation form was completed by 10% of the PCU RN staff. The staff identified that the process for obtaining each card was cumbersome and interrupted flow of care. The staff asked for a more efficient method to provide patient education.

Interpretations: The CNS reviewed the results of the pilot with the patient education team and a new medication education form was developed. The new form listed the medication information from each card in a table format on 1 page, front and back. The RN gives the medication form to the patient and circles the medications appropriate for the patient. Over a 1-month period of time, the CNS introduced the new medication education form and process to the nurse managers and nurse educators on each patient care unit of the hospital. Each unit manager and educator educated the RN staff on the process for use of the medication education form. Hospital-wide use of the new medication education form began within 2 months following the CNS-led pilot on the PCU.

Implications: Over a period of 2 months the use of the new medication education form hospital-wide resulted in an increase in the patient satisfaction with medication scores for the hospital. The hospital satisfaction with medication scores increased to the 85th percentile.

Increasing the Utilization of the Digital Library in an Interdisciplinary Setting: An Innovative CNS Collaboration Project

Shaw C, Pentek K, Carolinas Healthcare System, Charlotte, North Carolina

Purpose: Describe a CNS-led development of an innovative educational intervention for nurses and Invasive Cardiovascular Specialists on how to successfully and confidently access the hospital's digital health library and retrieve evidence-based articles that support clinical practice change. Create an environment for nurses and specialists to become confident when inquiring about evidence-based practice initiatives in the clinical practice setting.

Significance: The digital library supports the fact that ever changing technology is being made available for learning in the clinical practice setting. It is crucial that nurses and specialists have, and use, contemporary resources to improve and evaluate quality healthcare practices and outcomes. These initiatives are beneficial in shaping future quality patient outcomes and reimbursement practices in healthcare.

Background: A metro cardiovascular invasive catheterization laboratory consisting of 16 procedure suites and over 100 clinical staff members at 4 hospital locations. A large digital library hub is available for all staff members of the hospital system. Procedural settings within hospitals oftentimes are faced with diverse issues that revolve around clinical practices and policy development. The nurses and specialists are the front line staff that can influence practice change. A clinical nurse specialist (CNS) and Graduate Nursing Student collaborated to develop an interactive learning module for the Lab's clinical staff to develop research capabilities and enhance confidence in researching evidence. This educational intervention supports professional development, stimulates critical thinking skills and fosters a culture for evidence-based practice.

Method: A constructivist approach was used for this project. Phase I: A recruitment letter was emailed to all staff members, nurses and specialists. Five nurses and 2 specialists responded with their intent to participate. All completed the on-line pretraining needs assessment survey and the one-on-one interactive training module with the CNS and Graduate Nursing Student. Phase II: Each participant was required to successfully retrieve a research article. Phase III: An on-line posttraining electronic survey was given to all the participants.

Outcomes: The pretraining needs assessment indicated that over 50 percent of the participants lacked "all" confidence in utilizing the digital library program, followed by 30 percent acknowledging "little" confidence. The posttraining assessment indicated that 100 percent of the participant's confidence improved after training, 50 percent signified being "most" confident in utilizing the digital library.

Conclusions: Providing detailed training for accessing the digital health library is directly correlated with the confidence level of the participant when researching evidence. The clinical staff is able to utilize the appropriate contemporary resources when researching evidence to support clinical practice change.

Implications: The CNS influences the client and staff spheres by enhancing the staff's competency level in utilizing the digital library. Utilizing a unique and innovative learning approach reinforces the staff's ability to enhance and translate knowledge into practice.

Individual Perceptions of Collective Teamwork Among Army Forward Surgical Teams

Mittelsteadt PB, US Army Institute of Surgical Research, San Antonio, Texas; Marchok D, US Army, Heidelberg APO AE; Vanek A, US Army, Honolulu, Hawaii

Purpose: The 14-day Trauma Training Center Course, provides military medical team training for forward surgical teams (FSTs). The training design and implementation is heavily dependent on the 3 assigned military clinical nurse specialists (CNSs) who implement Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPs) System as the foundation of training. This article validates the impact of the use of CNSs and TeamSTEPPs training.

Significance: This course's overarching goal is to improve the survival rate of injured service members on the battlefield through a comprehensive training strategy. This strategy focuses on maximizing the combined team response and teamwork of the FST members as they encounter patients with traumatic injuries. Three military CNS instructors comprise 30% of the faculty and provide 70% of the didactic and clinical training.

Background: The CNS operates within all 3 of the spheres of influence. The CNS facilitates the growth of FST nursing staff by observing, demonstrating and evaluating interactions nurse to nurse, nurse to patient and nurse to system. A CNS might coach specific elements of effective communication between FST nurses while emphasizing that this promotes safe care for the patients and results in a systems efficiency of reducing time to task completion. Simply put, communicating a numerical order for multiple patients to undergo a computerized tomography scan based on triage can result in greater systems efficiency.

Description: FST personnel comprising 6 active duty and reserve FST teams (n = 122) were administered the TeamSTEPPS Teamwork Perception Questionnaire (T-TPQ) before starting training at ATTC. Constructs evaluated in the 35-question survey included: team structure, leadership, situation monitoring, mutual support, and communication; scores ranged from 1(strongly disagree) to 3 (neutral) to 5 (strongly agree). T-TPQ was administered a second time on graduation day at this course. Finally the T-TPQ was administered for a third time when the personnel were approximately 4 months into a combat deployment. Descriptive, repeated-measures analysis of variance and paired Student t tests were used to evaluate responses.

Outcome: The T-TPQ precourse results (n = 122) show FST members perceptions were strongly neutral (unsure) of the collective teamwork levels (mean, 3.4 +/- 0.12; range, 3.17-3.61). The T-TPQ results postcourse (n = 122) show FST members scored agreed or strongly agreed (mean, 4.32 +/- 0.17; range, 3.79-4.57) (P < .001); these findings were replicated within and across the 6 FSTs. The T-TPQ deployment results (n = 43; 30% response) show perceptions of collective teamwork exceeded both precourse and postcourse T-TPQ results (mean, 4.83 +/- 0.07; range, 4.74-4.91) (P < .001).

Interpretation/Conclusion: Clinical nurse specialist instructors play a significant role in assuring FST members maximize teamwork. FST member's perceptions of teamwork improved during course attendance and during a combat deployment, demonstrating a positive response to the CNS-driven training program.

Implication for Practice: Enhanced trauma team cohesion is associated with improved patient outcomes. This project could be implemented and evaluated at any facility that routinely uses trauma teams to improve teamwork and communication skills.

Influential Role of the Clinical Nurse Specialist in Improving Patient Satisfaction of Sleep in the Surgical Intensive Care Unit Through an Effective Sleep Program

Hata R, The Queen's Medical Center, Honolulu, Hawaii

Purpose: The CNS can play an influential role in bringing culture and mindset change for the SICU through an evidence-based practice team. The purpose of our project was to institutionalize evidence-based nonpharmacological nursing process for sleep management in the stable SICU patients.

Significance: Lack of sleep for the patients in the surgical intensive care units (SICU) is usually seen as "inevitable" and also dissatisfies patients. Because of this inevitable mindset and culture, sleep deprivation may be rarely addressed. Also, continuous stimulation and high noise levels related to alarms, equipment, and conversations add to the issue. Wake/sleep cycle is often altered which can cause delirium. The CNS is influential in impacting culture change.

Background: Per our unit-specific nurse assessment survey, 84% of the surveyed nurses felt that the patients did not get adequate amount of quality sleep in our SICU. Ten patients were assessed regarding their quality of sleep. Only 50% of the patients reported the ability to sleep and feeling rested. Literature indicates that noise within the ICU can be modified by human behavior such as awareness of noise levels and clustering care. Physiology and environmental influences can improve sleep patterns. In addition, designated "quiet time" can help the patients obtain sleep in the busy ICU environment.

Methods: The CNS partnered with a staff nurse to conduct baseline assessments. Using the Iowa model of evidence-based practice, a multidisciplinary team was formed to review the literature. The CNS taught staff nurses critique articles and synthesize summary statement for a nursing guideline. The CNS coached the group to develop a performance improvement project related to sleep promotion. Together, a sleep program was developed for the stable SICU patients, allowing stable patients to obtain uninterrupted sleep for 4 hours at night. Multiple discussions regarding significance of sleep and implications were conducted with physicians, nurses, and respiratory therapists. The importance of sleep was integrated into daily multidisciplinary rounds. Standard order template and evaluation tools were developed, in addition to other tools that can be utilized for the program implementation.

Outcomes: The SICU Sleep Program improved the patient's quality of sleep. Of the 54 completed patient evaluations obtained by the staff nurses, 78% of the time the patients reported that they were able to sleep (vs 50% prior to program). In addition, 69% of the time the patients reported that they felt rested (vs 50% prior to program).

Conclusions: By asking the patient's about barriers, the nurses became aware of improvement opportunities. Overall, this project improved quality of sleep for stable SICU patients while increasing awareness of patient's perception to the nurses. The success of our sleep program was due to the coordination of the CNS engaging multiple disciplines in this significant journey. Continual engagement of staff for idea input and feedback were crucial for this success.

Implications: The CNS impacts culture changes and mindsets. The CNS plays a valuable role in empowering nurses with nonpharmacological interventions (such as sleep) in promoting healing. Such CNS-led sleep programs for the SICU potentially decreases length of stay while increasing patient satisfaction and nurses' perception of sleep quality.

Innovation Outside the Lines: A Clinical Advancement Program in a Multidisciplinary Procedural Setting

Shaw C, Carolinas Healthcare System, Charlotte, North Carolina

Purpose: Describe how the clinical nurse specialist (CNS) used an innovative, evidence-based approach to implement a clinical advancement program for an interdisciplinary team of Invasive Cardiovascular Specialists.

Significance: In procedural settings, such as a cardiovascular invasive laboratories, it is uncommon to have a clinical advancement program available for nonnursing clinical staff. Providing an advancement program for the Specialists, improves the individual's practice, promotes growth, and enhances job satisfaction and organizational objectives.

Background: Setting: A metro cardiovascular invasive catheterization laboratory consisting of 16 procedure suites and over 100 primarily nonnursing clinical staff members at 4 hospital locations. Opportunities for advancement by promotion within the catheterization laboratory are very infrequent and limited due to low turnover of leadership positions. It is common for cardiovascular specialists to leave the organization for more engaging and financially rewarding opportunities. The new clinical advancement program creates a second ladder, a nonleadership track, for advancement.

Method: A CNS-led multidisciplinary team of cardiovascular specialists, nurses, educators, administrators, shared governance representatives, and human resource specialists collaborated to develop a clinical ladder program paralleling the existing program available for nursing. Utilizing the Rosswurm and Larrabee Evidence Based Practice Model, a detailed proposal/program was submitted to the unit based shared governance council followed by the human resources department.

Outcomes: The clinical advancement program for the invasive cardiovascular specialists was endorsed by the executive leadership of the organization. A CNS-led focus group consisting of a specialist, a registered nurse, and a catheterization laboratory manager was formed to implement, evaluate, and maintain the clinical advancement program in the department. The program was formally introduced to the specialists at a monthly staff meeting. A clinical ladder page was added to the department's internal Web site as a hub for information and communication regarding the new program.

Conclusions: Several qualified specialists have recognized the value of the program and are pursuing the opportunity for professional and salary advancement. The CNS role is to mentor these individuals to successfully advance in the program.

Implications: The CNS influences the client/staff and organization spheres by expanding the scope of focus and introducing innovation into a multidisciplinary setting. Ladder programs are essential for developing specialists professionally and personally. This program promotes productivity, staff versatility, enhances staff retention and morale, as well as, job satisfaction and cost reduction. This innovative practice supports healthcare change by retaining qualified staff to improve overall quality patient outcomes, as well as enhancing cost efficiency and organizational goals.

Innovative Delirium Care: The Role of the Clinical Nurse Specialist in the Implementation and Sustainability of a Practice Change in an Acute Care Hospital

Babine RL, Bradstreet P, Honess C, Todorich P, Maine Medical Center, Portland

Purpose: The purpose of this project was to evaluate the effectiveness of the role of the CNS in the implementation and sustainability of a practice change related to delirium screening on 3 adult inpatient medical units in an acute care hospital.

Significance: Clinical nurse specialists with expert skills in systems management, nursing education and patient care are imperative to implementing innovative practice changes in a healthcare system. Background Delirium is an altered state of consciousness accompanied by a change in cognition that develops over a few hours or days and tends to have a fluctuating course. Delirium is strongly associated with negative outcomes, including: an increase in death and complications while in the hospital, prolonged hospital stays and nursing home placement. Description An institutional policy was implemented stating that the Confusion Assessment Method (CAM) should be performed by the RN on all adult medical/surgical patients upon admission, transfer, daily, and with any changes in cognition. Interdisciplinary delirium education in the form of a live presentation was offered several times over a 2-week period prior to the institution of the practice change. In addition to live classes, other forms of education (express inservice, presentation w/voice over, resource tools) were available to staff. Additional "doses" of education were offered at 3, 6, and 12 months after implementation. To determine education sustainability, the documentation and completion of the CAM was audited weekly, until a goal of 75% for an average of the 3 medical units was achieved. Once the goal was met for 3 consecutive weeks, the frequency of the audits was decreased to every other week and continued for 1 year after implementation. To determine accuracy, a CAM screening was performed by a clinical expert in delirium, while study staff collected data and obtained bedside RN CAM results. Discrepancies between the expert and RN screenings were documented, and education was performed if needed. Outcome Audit results were disseminated to nursing units when completed for real time feedback. The documentation and completion audit goal of 75% was met on week 17, and has been maintained for 6 months. Analysis of the CAM screening accuracy is in process. Interpretation/Conclusion When instituting an innovative practice change in a large tertiary care hospital, it is beneficial to divide patient care units into "cohorts" and systematically "roll-out" the initiative throughout the institution. Focusing on 1 "cohort" at a time ensures sustainability of the desired practice change. We are currently disseminating this practice change to all adult inpatient areas within our institution.

Implications for Practice: Clinical nurse specialist availability on the patient care units to offer support during implementation is imperative to staff acceptance of a new initiative. To ensure sustainability of a practice change, continued education is a crucial and often an overlooked component in the planning and implementation stages. By revisiting the content systematically with "doses" of education in different forms, staff is given the opportunity to ask further questions thereby increasing knowledge and retention of material.

Innovative Learning Strategies Using Technology: Translating Evidence to Practice

Gunn S, Baylor Healthcare System, Dallas, Texas

Purpose: (1) By the end of this session the participants will examine interactive learning strategies that align with adult learning principles. (2) Describe the role of the CNS in implementing research into practice.

Significance: Clinical nurse specialists (CNSs) change agents, clinical experts, and innovators, to name a few of our roles. Our diverse capabilities provide us with expertise to implement innovative approaches to nursing practice issues. One of these issues is presenting evidence-based content to a multigenerational workforce that is engaging and enlightening. The use of technology has opened the door to a multitude of virtual possibilities that is ripe for CNSs to participate in. Innovative approaches to learning, using technology, appeals to adult learning principles, a multigenerational workforce, and a workforce that needs 24/7 availability of resources.

Design: This is a project designed to implement research into practice and improve the outcomes of geriatric patients. The role of the CNS in helping design the project infrastructure, evidence-based content, and outcome measures is the focus of this session.

Methods: An infrastructure to design content related to innovative learning strategies around geriatric care was designed by the CNS. Evidence-based clinical content was created based on this infrastructure and embedded into a variety of technological teaching strategies. Approaches to learning included face-to-face, iBooks, and e-learning related to the care of the geriatric patient. The use of virtual gaming is also part of this project. Examples of different learning strategies will be discussed and presented.

Findings: Adult learning principles must engage the learner and be relevant to practice. By providing engaging interactive content, learners from multiple generations and learning preferences can be reached. Clinical nurse specialists are vital team players in implementing change within 1 or more spheres of influence.

Conclusions: The role of the CNS as innovator and change agent can be diverse, but the principles of change management, developing a sound infrastructure, and developing the workforce are universal concepts for the CNS role.

Implications for Practice: The goal of this project is to provide free access to a variety of virtual nursing education on geriatric care to a worldwide audience. Hopefully, this will be one approach to improving healthcare and outcomes for our aging population.

Innovative Strategies for Patient Medication Education: The Evaluation of Nurse's Teach-Back Technique Using Kirkpatrick's Levels of Evaluation

Fara-Erny AM, Indiana University Health, West Hospital, Avon

Objective: The objective of this clinical improvement was to enhance tools and resources for nurses providing patient/family medication education in acute care. Clinical nurse specialist (CNS) interventions touched on all 3 spheres of influence. Effective education of patients faltered with complex populations, various levels of nursing experience with literacy and education, and a lack of system support for consistent medication education processes and resources.

Significance: Clinical nurse specialist interviews with readmitted patients raised concern about the effectiveness of medication instruction. Patient experience scores showed a need for improvement in the areas of drug adverse effects and actions. Nurses were frustrated with the lack of time for targeted patient education that was consistent and met the needs of complex patients. Clinical nurse specialist intervention sought to improve patient satisfaction, provide safe medication practices after discharge, reduce readmissions, and elevate the practice of nurse's teaching strategies.

Methods: The CNS engaged a motivated bedside nurse to explore options to improve patient education. They cochaired an interdisciplinary team to explore patient literacy, assess education barriers, and develop effective means for patient medication teaching. Recognized as areas for improvement included variable bedside nursing experience and education techniques, variable structure and process for education, poor understanding of the impact of low health literacy, staff frustration with a lack of time for patient education The team reviewed literature (Lamiami and Furey, 2009; AMA, 1999; Villaire and Mayer, 2007) related to patient health literacy and adopted The teach-back method of education. Implementation included "What Every Caregiver Should Know About Patient Literacy and Teach Back" brochures and didactic education of staff from all departments with competency validation. Once education was complete, a learning module containing a video on patient literacy was assigned to all facility RNs.

Outcomes: Evaluation of interventions include both the patient and nurse. Education outcomes were assessed by tracking experience scores for medication instruction. Scores improved in the initial few months from 55% to 68%. To fully assess the behavior changes and skills from teach back, the bedside nurse leader, 2 CNSs, and the patient education coordinator conducted rounds based on the tenets of Kirkpatrick's 4 levels of learner evaluation (reaction, learning, behavior, and results). They observed a medication pass with 20 nurses focusing on teach back technique providing real time feedback for improvement. Results indicated that nurses performed teach back with some insecurity, and improved with real-time coaching the rounds provided. Nurses were pressured for time due to the number of medications passed. In addition, patients were confused by a lack of consistent action and adverse effect stated for drugs.

Conclusions: This process provides continual improvement with outcome assessments and rounding. Currently, medication adverse effects and actions for each unit's top 15 medications have been provided to staff on badge hang tags for consistent patient education, with follow-up rounding pending.

Implications for Practice: Clinical nurse specialists frequently provide evidence-based interventions to increase patient care quality and nurse competence. It is imperative that we evaluate our intervention beyond the reaction and testing of learners to include learned behavior and outcomes.

Integrative Competency Framework for Clinical Nurse Specialist Transition to Practice

Ecoff LA, Sitzer V, Sharp Memorial Hospital, San Diego, California

Purpose: The purpose of this project was to develop an integrative competency framework for clinical nurse specialist (CNS) transition to practice. Objectives included the identification of relevant CNS, graduate and advanced practice competencies and the development of relevant role expectations that assist the new CNS and preceptor in competency assessment and validation.

Significance: The Institute of Medicine, Future of Nursing Report recommends completion of a transition to practice program for graduates of prelicensure and advanced practice degree programs. This led to an examination of orientation practices in 1 healthcare organization and the development of an integrative competency framework for CNS transition to practice.

Design (Background/Rationale): In the current healthcare environment, it is imperative that CNSs be competent to lead efforts to achieve exemplary patient, nursing workforce and organizational outcomes. With the multiple professional organization CNS, advanced practice nurse, and graduate level competencies including those from the National Association of Clinical Nurse Specialist, the Quality and Safety Education for Nurses, the American Nurses Association Nursing Scope and Standards of Practice and organizational initiatives for nursing excellence such as the Magnet Recognition Program, this organization embarked on integrating all source documents into an integrative competency framework.

Description of Methods: Competencies from the source documents were written on Post-It notes. Using a card sort technique, the competencies were sorted into like categories. An initial target of 10 competencies was set as a guideline for initial role orientation. Several rounds of sorting occurred and the final competency categories were placed within 3 domains of influence. Using a Delphi technique, current CNSs were asked to rate their level of agreement as to whether or not the competency was applicable to CNS role development. A content validity index score was calculated and all proposed competencies were retained. In a second Delphi round, CNSs were asked to rate the level of relevance to expanded content within each competency. Several content areas within the competency framework were discarded as not relevant to the CNS role. Upon completion of the Delphi process, a gap analysis was conducted and competencies were identified for revision or development. Competencies were structured using Benner's and Bloom's frameworks.

Findings/Outcomes: The integrative competency framework for CNS transition to practice consists of 12 competencies reflective of the source documents. Each competency describes novice to expert role development criteria within the cognitive, psychomotor, and affective domains of competence.

Conclusions/Interpretations: Through integration of multiple CNS and advanced practice nurse role expectations and collaboration with experienced CNSs in practice, this project resulted in a comprehensive yet streamlined role development program for new CNSs.

Implications for Practice: An integrative competency framework can assist the new CNS to transition efficiently and effectively into the role and to identify future growth and development needs.

Joint Ventures for Patients and the Healthcare Team

Davenport Johnson D, South Texas Veterans Healthcare, San Antonio; Martinelli D, Browning L, Purdue University Calumet, Hammond, Indiana

Purpose/Objectives: The purpose of this project is to determine if patients with joint replacement surgery that received preoperative education prior to surgery reported lower levels of pain than those who did not receive pain management education?

Significance: A review of the current evidence supports interdisciplinary patient education programs to decrease anxiety and improve outcomes.

Design (Background/Rationale): In an attempt to decrease anxiety for patients who are soon to undergo an operation it was identified that there was a lack of standardized preoperative education which addressed the most common postoperative issues experienced by patients who have undergone a total knee replacement.

Description of Methods: Provide effective patient centered pain management through developing a preoperative pain management education class to include an interdisciplinary approach including: pain management, diet, exercise and deep vein thrombosis prevention. National Association of Orthopaedic Nurses patient education series for Total Knee Replacement and Krames on demand patient education including understanding of chronic pain, communicating about pain and managing postoperative pain. Staff nurses on the postoperative unit received education on pain assessment. Pain will be assessed by current computerized patient record system template on thorough Pain assessment and reassessment to attain patient's goal of managing pain to an acceptable level, and evidence of relief of pain. Care coordination, disease prevention, health promotion are all utilized to optimize pain management.

Findings/Outcomes: Formative evaluation of this project indicates that patients who received pain management education compared with those who did not had shorter lengths of stay by 1.5 days on average, and reported unacceptable pain level prior to reaching a higher level of pain, as well as consistent lower levels of pain. Pain documentation monitoring reports indicate unit compliance rate of 99% since the initiation of the pain education class.

Conclusions/Interpretations: Preoperative education improves patient management of pain and decreases length of stay.

Implications for Practice: Patient and staff education classes on pain with an interdisciplinary approach are recommended to optimize pain management, care coordination, disease prevention and health promotion.

Leading and Engaging: Major Improvement Teams to Achieve Quality Nurse-Sensitive Outcomes

Reising DL, Allen M, Balaguras J, Holly VW, Kathman J, Pashikanti L, Wellman DS, Indiana University Health Bloomington Hospital, Bloomington

Purpose: In this presentation, the organization's clinical nurse specialists (CNSs) will describe a structure and process for the implementation of major improvement teams (MITs).

Significance: Achieving high quality nurse-sensitive patient outcomes is a key requirement for Magnet designation. Critical patient outcomes including falls, hospital-acquired pressure ulcers, hospital-acquired infections, and pain management are directly affected by implementation of best practices by nurses.

Background/Rationale: Key empirical outcome indicators in Magnet designation include nurse-sensitive quality outcome measures. This empirical outcome requires that a majority of units outperform the database benchmark a majority of the time for 2 consecutive years leading up to the organization's Magnet application. Clinical nurse specialists lead and effect change to impact nurse-sensitive indicators required for Magnet designation.

Description of Methods: The MITs are structured with a CNS leader, direct care nurses, clinical educators, leadership, and interdisciplinary members. The teams evaluate best evidence on improving nurse-sensitive indicators reportable in Magnet designation. The MITs are empowered to be flexible, allowing time to engage in "deep dives" aimed at solving problems that require a closer look at processes. The teams collaborate with existing shared governance structures of practice, education, quality, executive, and research councils to implement interventions for maximum results. The MITs are responsible for collecting and evaluating process and outcome data on nurse-sensitive indicators, and leveraging the support necessary to implement change. Some examples of resources used to improve outcomes include equipment to prevent pressure ulcers, retreats to improve communication strategies, and electronic documentation changes to ensure proper referral and reminders to healthcare providers.

Outcomes: Sequential reductions in hospital-acquired conditions, and increases in pain well-controlled have been realized progressively since 2010: HAPU: 2010 = 2.4, 2011 = 1.4, 2012 YTD = 0.8 falls: 2010 = 3.1, 2011 = 2.9, 2012 YTD = 2.5 VAP: 2010 = 3.4, 2011 = 3.1, 2012 YTD = 0 CLABSI: 2010 = 1.7, 2011 = 1.55, 2012 YTD <= 0.5 CAUTI: 2010 = 2.9, 2011 = 1.26, 2012 YTD <= 0.5 Hospital Consumer Assessment of Healthcare Providers and Systems "Pain well controlled" always: 2010 = 52.6%, 2011 = 60.2%, 2012 YTD = 63.3%.

Conclusions/Interpretations: Since their inception, the MITs have effected declines in hospital-acquired pressure ulcers, falls, catheter-associated urinary tract infections, central line-associated bloodstream infections, ventilator-associated pneumonia, and improvements in pain management. The leadership of the CNSs who bring skills in evidence-based practice (EBP) implementation, and collaboration skills, were critical to implementing a successful and sustained change for improving patient care at the bedside.

Implications: The goals supported in Magnet designation are also critical in the current value-based purchasing environment where high quality patient outcomes drive the reimbursement level. Clinical nurse specialists lead many initiatives that drive quality in Magnet designation and reimbursement. Using a team structure that involves the CNS as a lead, a champion administrator, a champion educator, and interdisciplinary direct care givers is an effective strategy for designing EBP practice in a manner that is consistent with models of change for sustainability.

Leading and Sharing the Complex Care Journey With Childbearing Women/Critically Ill Children: The Role of the Clinical Nurse Specialist

McCarthy RV, Basso M, Children's and Women's Health Center of BC, Vancouver, Canada

Purpose: This presentation examines the care needs of the complex child and family and the childbearing woman and family in the exceedingly complex world of the quaternary care center; and examines the advanced practice skills the clinical nurse specialist (CNS) uses when working with these clients.

Significance: Critically ill children and childbearing women are increasingly likely to have complex problems in our current practice context. These complex problems may be encountered over a short or very long hospital stay.

Design: Clinical nurse specialists are involved with children, women and families who do not fit the norm or the usual and expected path of care. Leading from a place of conviction requires comfort with advanced practice nursing skills to meet complex needs.

Methods: Stories of 2 clients and families with complex care needs will be shared and compared with those of clients falling in the expected range of care. The process of team coordination to develop complex care plans will be outlined.

Outcomes: The outcomes following use of care plans to meet complex care needs will be described and assessed for the potential for improved care delivery related to CNS involvement.

Conclusions: The CNS role has been found valuable by families, nurses, physicians and allied health team members when caring for the complex critically ill child or childbearing woman in quaternary healthcare.

Implications: The path of development of care plans for complex clients will be addressed and discussed for potential use in similar settings.

Looking Forward to the New Age of Healthcare: Elder Care. What a Great Time to Be a Clinical Nurse Specialist!

Duffy Dionne J, Exempla Lutheran Medical Center, Westminster, Colorado

Purpose: The purpose of this abstract is to discuss the influence and roles of the CNS in the planning, development, implementation and leadership of a new geriatric emergency department in a 230-bed community hospital outside of Denver Colorado.

Significance: There is a movement in the United States to open specialized geriatric emergency departments (EDs), a unit that is physically designed for the elderly patient and where there are specialized screenings to look at the risks that may be facing these patients. The clinical nurse specialist (CNS) is prepared to research, plan and implement a nursing model and a specialized geriatric ED unit to give special care to this elder population.

Background/Rationale: In a community hospital in the Denver metropolitan area, the senior leadership team put the creation and opening of a geriatric ED as a priority for 2011. It was decided that a program manager was necessary to plan, design, implement and manage the day to day operations of this unit. The CNS was identified as the leader for this change process.

Methods: A Steering committee was convened to make decisions about the physical design of the unit. This committee was cochaired by a facilities person and the CNS. Evidence-based research and data review was done by the CNS to identify tools to use for risk screening, what physical changes needed to be complete. A "core group" of RNs and Technicians was convened to "open" the unit. The CNS was the educator, consultant and expert clinician to the Nursing staff and physicians in the weeks leading up to the opening of the unit. All education was complete prior to the opening and a "day in the life" was coordinated by the CNS.

Outcomes: The "senior ED" was opened to patients on October 4, 2011, and as of September 10, 2012, has had over 8000 patients come through its doors. Twenty-two percent of the patients from the "senior ED" have been admitted as inpatients, 52% have been sent home and the balance of patients have been discharged to a nursing or rehabilitation facility. One hundred percent of the "senior ED" patients have been screened with 5 different tools to identify risks to health, functional decline, and needed resources and appropriate referrals have been made based on these screenings. The CNS oversees the day to day functions of this special unit and delivers all education and data collection for this special. Patient satisfaction scores have been in the 90% for this unit surpassing the "regular ED" by at least 30%.

Conclusions: The CNS was instrumental in the design, planning, implementation and overall management of the "senior ED" that has increased patient satisfaction scores and appropriate discharges for the patients over 65 years of age.

Implications As our population ages more specialized senior EDs will be needed. The CNS is the perfect person the lead the charge to accommodate the needs of elders in the ED with new nursing care models, patient screening and education of staff. It's a GREAT time to be a CNS!

Making the Most of Your Clinical Nurse Specialist Practicum

Hill KM, Cleveland Clinic, Broadview Heights, Ohio

Significance: The clinical nurse specialist (CNS) practicum should be a shared activity, with the clinical faculty and student making decisions about what is most important for growth. If there is a lack of engagement in this process, the result can be exhausted clinical faculty and frustrated students. Developing clinical rotations with the guiding principle of autonomous advanced practice will produce a more confident CNS graduate.

Design: Graduate education is less structured than the entry into practice curriculum, and new graduate students may find the options daunting and confusing. Many nurses, though possessing years of critical care experience, have no idea how to negotiate an individual clinical practicum, or how to find mentors who can give beneficial guidance for a chosen role. The stakes are high, as a poorly chosen or executed clinical experience, means lost time, money, and growth.

Description: Through a series of exemplars, the participant will be able to identify strategies for making the most of clinical experiences outside the classroom.

Outcomes: The presentation will provide practical strategies for finding clinical faculty who will welcome CNS students, identify clinical projects that showcase skills, and provide an environment for mutual evaluation of the student and clinical site for future employment.

Conclusions: Clinical nurse specialist clinical experiences are loosely structured and rely on the individual investigation and negotiation skills of the student to produce a meaningful experience.

Implications for Practice: This presentation will help the CNS student and clinical faculty member analyze personal interests and motivations, identify golden opportunities for growth, and maximize graduate school experiences so as to be positioned for success even before the ink is dry on the diploma.

Measuring Impact of Patient- and Family-Centered Rounds

LaBorde P, University of Arkansas for Medical Sciences Hospital, Bryant

Significance: The struggle for hospitals to decrease length of stay (LOS) while maintaining appropriate care and involving patients in their plan of care (POC) helps to create an opportune time for a CNS to facilitate the development of a process to improve communication, collaboration, and coordination of patient care.

Background: The concept of patient rounds, in 1 format or another, is not a new concept in many hospitals. However, the effectiveness of the rounding activity on LOS and interdisciplinary collaboration to include patients and families is not well documented. The need to address these areas led to a CNS-facilitated pilot initiative on a 30-bed medical inpatient unit in an academic university medical center in the Southern United States. Increasing LOS, delays in discharge, poor communication between team members about POC and patient dissatisfaction around discharge planning helped to drive an initiative of developing patient- and family-centered care (PFCC) rounds. The purpose of PFCC rounds is to provide a standardized approach to daily rounding which engages patients, families, and the entire healthcare team in the development and coordination of the patient's POC.

Methods: Using a process improvement methodology, a CNS utilized concepts of a system's sphere of influence to facilitate medical and nursing leadership participation in an initiative aimed at the development of PFCC rounds to answer the question: does PFCC rounds affect LOS, coordination of patient care, patient satisfaction and increased collaboration with team members, patients, and families? This collaborative process involved weekly planning meetings of key stakeholders to discuss the key requirements of PFCC rounds, review of data regarding LOS and discharge process for the unit. Patient- and family-centered care rounds were implemented on the unit and progress was reviewed by the key stakeholders.

Findings/Outcomes: After a 6 month period, analysis revealed higher collaboration and communication between medical and nursing staff regarding patients' POC. Significant improvement was noted in eleven key patient satisfaction indicators. Average LOS reduced from 5.8 days in fourth quarter 2011 when the project began to a current average LOS of 4.8 days. In addition, the CNS was able to discover and assist with clinical issues noted during rounds, as well as, mentoring and developing staff during real-time teaching moments to address the clinical issues.

Conclusions: Patient- and family-centered care rounds have proven to be an effective method for the team to promote timely and efficient care and discharges. Improved communication between caregivers strengthened which in turn was reflected in the impact on patient satisfaction and LOS.

Implications: Patient- and family-centered care rounds benefit patients and families by engaging them in their care. Improved communication through information sharing helps all involved move towards better patient outcomes and a shared responsibility in care. The CNS plays a vital role in facilitating PFCC rounds through ongoing mentoring of nursing staff and providing feedback to medical team.

Medication Administration, Patient Safety, and Nursing Workflow: How Bar-Code Scanning Technology Will Help

Bird A, Essentia Health East, Duluth, Minnesota

Objective: The clinical nurse specialist is well positioned, due to educational preparation and clinical experience as an advanced practice nurse, to lead nursing staff in the development, education, implementation, and evaluation of practice changes. This presentation will review the journey of an integrated healthcare system's addition of bar-code scanning technology into the medication administration workflow.

Significance: Medication administration is a critical process requiring multiple steps to help ensure safe patient care and has been identified to help increase the safety of medication administration. Studies have found more than one-third of preventable medication errors occur during the administration stage. Bar-code scanning can help decrease these administration errors.

Rationale: The integrated healthcare system identified an increase in reported medication errors related to the administration stage of the workflow and due to missing 1 or more of the 5 Rights of Medication Administration: right patient, right medication, right dose, right route, and right time. Adding bar-code scanning technology into the medication administration workflow can be effective at improving patient safety at the bedside, while increasing the efficiency of the nursing workflow.

Description of Methods: Bedside nurses were identified to be essential in the integration process. Therefore, a "taskforce" was formed of nurses from multiple patient care settings and was charged with the responsibility to develop a new nursing workflow that would eventually support the bar-code medication administration (BCMA) process. A meta-analysis of relevant BCMA literature and a review of the Centers for Medicare & Medicaid Services' and the Institute for Safe Medication Practice's guidelines on medication administration was completed. Following workflow redesign principles, high-level flowcharts of the current and future-state medication administration workflows were created: beginning with the medication in hand and ending with postadministration documentation. Subsequent to the development of the future-state workflow, the taskforce completed an FMEA (failure, modes, effects, analysis) to help identify system concerns, barriers, and potential workarounds.

Outcomes: The FMEA identified areas of potential workarounds in the BCMA process, allowed for the development of an ideal education process, and helped to ensure the future-state workflow would support safe medication administration practices at the bedside, focusing on hardwiring the 5 Rights of Medication Administration.

Interpretations: Reducing medication errors is one of the most significant measures a hospital can use for patient safety. Bar-code scanning technology can assist with this reduction, however it is essential for nursing to identify the workflow process to help secure peer buy-in and maintain the system or process change.

Implications for Practice: Implementing bar-code scanning technology into the medication administration process will demonstrate a decrease in reported medication administration errors, increase staff awareness and adherence to the 5 Rights of Medication Administration, and increase compliance with timely documentation. Finally, the increase in efficiency will provide the nurse more time at the bedside devoted to patient care.

Moral Distress Within the Interprofessional Team

Johnson MT, Chula Vista, California

Moral distress (MD) has been studied extensively among registered nurses (RNs) in the critical care setting. Little is known about this phenomenon among other professionals within the critical care interprofessional team (eg, nurses, physicians, social workers, respiratory care practitioners, and pharmacists). Moral distress has been linked to staff burnout, dissatisfaction, and turnover. There is also literature that suggests that these factors can contribute to patients receiving poor care. This study will identify situations that cause frequent and/or intense episodes of MD among these professional groups. Moral distress was first defined in the literature by Andrew Jameton (1984) as the inability of a nurse to implement a morally correct course of action due to organizational constraints. Constraints identified in the literature include excessive workloads, caring for dying patients, administrative conflicts, interprofessional team communication problems, lack of time, supervisory reluctance, and an inhibiting medical power structure. This definition was later used by Wilkinson (1987/1988) as the foundation for a qualitative study which identified sources of MD among registered nurses. Corley (1995) conducted the next study on MD, which influenced the development of the Moral Distress Scale (MDS). This scale identifies the frequency and intensity of MD experienced based on various clinical situations. This scale has been used in several nursing studies since that time exploring this phenomenon among RNs, especially those in critical care. Commonly cited frequent sources of MD among RNs include RNs' perception that they were following the wishes of someone other than the patient (eg, family members), acting in a particular fashion per the request of organizational leaders (due to fear of a lawsuit) or working with inadequate levels of staff. Situations causing the most intense feelings of MD among RNs include prolonging life, performing unnecessary tests and treatments, lying to patients, continuing to participate in care for a hopeless ill person who is being sustained on a mechanical ventilator, initiating life saving interventions when it is perceived it will prolong death, and following the family's wishes for a patient's care when I do not agree with them but do so because hospital administration fears a lawsuit. To identify situations causing frequent and/or intense experiences of MD among nurses, physicians and other allied health professionals, the Moral Distress Scale-Revised (MDS-R) was developed by Drs Hamric and Corley in 2007. The MDS-R will be used in this study to identify the clinical situations that cause frequent and/or intense feelings of MD among nurses, physicians, social workers, respiratory care practitioners, and pharmacists working in the critical care setting. Quantitative data will be analyzed using nonparametric statistics including frequencies, means and percentages to describe the sample, and parametric statistics will be used to analyze all nominal, ordinal, interval and ratio level data. Analysis will be conducted using SPSS v20.0. Psychometric testing will be performed on the MDS-R used for each discipline to determine the reliability and construct validity of the MDS-R for each discipline. Findings, conclusions and implications will be discussed once the data analysis is completed.

Navigating Nutrition: Providing Optimal Nutritional Support to Improve Patient Outcomes

Powers J, St Vincent Hospital, Indianapolis, Indiana

Significance: Latest evidence-based guidelines support the initiation of enteral nutritional support within 24 to 48 hours of intensive care unit admission. Nurses play a pivotal role in assuring that nutrition is initiated in a timely manner. Through nurse-driven protocols, the nurse plays an active role in assuring timely and appropriate nutritional support is delivered in order to positively affect patient outcomes. A thorough understanding of the benefits of enteral nutrition is essential for all healthcare providers. Placement of feeding tubes at the bedside facilitates early enteral nutrition in order to achieve optimal patient outcomes. Bedside placement also decreases the risks associated with patient transport. Recent evidence-based guidelines will be reviewed for initiation and management of enteral nutrition.

Design: The purpose of this session is to develop an understanding of the importance of enteral nutrition and to implement evidence-based guidelines for initiation and maintenance of nutritional support. The presentation will also include a review of various methods for bedside placement of feeding tubes in order to facilitate the delivery of early enteral nutrition. Current research studies will also be incorporated into the presentation.

Methods: This presentation will discuss our clinical nurse specialist led performance improvement initiative focused on implementation of bedside placement of small bowel feeding tubes and early initiation of enteral nutrition in our patients. Findings Initiation of feeding tube placement at the bedside facilitated early enteral nutrition consistent with evidence-based guidelines. This initiative also resulted in a significant decrease in the use of total parenteral nutrition at our institution. The development of a nurse-driven protocol for initiation of enteral nutrition was a key factor to our improvement effort. Through the use of an electromagnetic placement device, we have also been able to eliminate radiographs for feeding tube confirmation, improved safety of feeding tube placement and decrease associated costs. Conclusion Through initiation of early enteral nutrition we have been able to successfully demonstrate a reduction of total parenteral nutrition use resulting in over a million dollars in cost savings. Additional cost savings have resulted from this initiative including elimination of multiple radiographs and in our intensive care unit patients, total elimination of radiographs for confirmation of feeding tube placement. In addition to these benefits we have also demonstrated improved safety with feeding tube placement.

Implications: The clinical nurse specialist plays a critical role in facilitating best practice through facilitation of evidence-based nursing practices. Successfully facilitating the placement of feeding tubes and timely initiation of enteral nutrition is 1 example of improved nursing practice resulting in positive patient outcomes, improved safety, and significant cost savings at our institution.

Nursing Practices of Insulin Administration at Mealtimes

Lampe J, Chamberlain L, Penoyer D, Orlando Health, Florida

Significance and Background: Rapid-acting analog (RAA) insulins are used routinely for mealtime insulin treatment in acute care. Rapid-acting analog insulins must be given within 15 minutes of meal consumption (before or after) to reduce the risk of hypoglycemia. Nurses must time insulin around meals appropriately. In April of 2010, our organization changed the formulary insulin from regular to lispro, a RAA, on all sliding scale orders and mealtime bolus insulin doses. It is also recommended that point-of-care testing (POCT) be obtained no more than 1 hour prior to administration of mealtime insulin. It is not known whether nursing practice regarding mealtime insulin administration has changed to reflect the RAA and POCT recommendations.

Purpose: The primary aim of this study was to determine nursing practices associated with the timing of RAA insulin administration around meal consumption. Secondary aims included detecting signs and symptoms of hypoglycemia in patients who received RAA insulin and identifying opportunities to better coordinate administration of RAA insulins around meals.

Methods: This was a descriptive, observational study of nursing activities during RAA insulin administration at mealtimes. Sixty-three nurses from 4 cardiology units were observed. All of the observers were trained by the principle investigator. Interrater reliability was established between observers. Observers recorded the time of tray delivery, first bite of meal, and insulin administration using a stopwatch calibrated to the organization's network clock for accuracy. Times for point of care blood glucose testing (POCT) were obtained through the clinical information system, which also uses the network clock. Observers also asked nurses questions regarding patient's meal consumption and signs of hypoglycemia approximately 2 to 3 hours after insulin administration. Our goal was to observe 60% of the nurses who administer mealtime insulin on these units.

Results: The mean time between POCT and insulin administration was 01:14:43 (n = 61). Times ranged from -02:53:00 (before) to 00:11:40 (after) insulin administration. In 22 observations (36.1%), POCT was done within 1 hour of insulin administration. The mean time between first bite of the meal and insulin administration was -00:05:24 (before) insulin administration. The time between bite and insulin ranged from -02:28:00 (before) to 01:18:14 (after) insulin administration. Only 22 patients (38.6%) received insulin 15 minutes before or after first bite. Perfect care was defined as POCT no more than 1 hour prior to insulin administration and insulin administered within 15 minutes (before or after) the meal occurred in 9 of the 63 observations (14.2%).

Conclusions: The timing of mealtime insulin administration is not consistent with current recommendations, and practice varies between nurses and units. The observers noted a general "unawareness" of meal delivery and that practice was "task-oriented," rather than coordinated with meals. These findings are consistent with similar research and performance improvements in the literature.

Implications for Practice: This study provided a picture of current mealtime insulin administration practices on 4 cardiology units. The reasons for this deviation in recommended practice are not clearly understood. The results of this study indicate a need to identify barriers and implement strategies to promote best practice.

Nursing Students' and Nursing Staff's Perceptions of Students' Clinical Experience

Woodard T, Herzer L, Hart Tipton P, LaPrade M, Song J, Scott and White Healthcare, Temple, Texas

Purpose: Despite clinical being an integral part of nursing students' education limited information exists on the ideal experience. A supportive environment is vital for learning. It is anticipated that nursing units that are focused on being learning environments could increase student and nurse satisfaction. The study purposes were: (1) Examine the psychometric properties of 22 item staff and 20 item student surveys and (2) compare students' and staff's attitudes and experiences concerning clinical utilizing the 2 surveys.

Significance: The clinical experience is an integral part of the nursing student's education. Many entry to practice students spend at least half of their time during nursing school in direct care settings (ie, acute care, long-term care).

Design: A descriptive comparative study was conducted because there is limited information available describing the ideal clinical learning situation.

Description of Methods: The study utilized research team developed staff and student surveys. Survey development included a literature review and content validity rating by staff, faculty, and students. Staff and students were requested to complete their respective surveys twice to measure stability. Only 7 staff completed the survey twice prohibiting stability testing. There were 77 students and 33 retakers. For each survey, internal consistency analysis was conducted.

Findings/Outcomes: Correlations were found on several staff survey items including: (1) Staff availability to students corresponded with an increase competence in working with students; and (2) Having input in how students met learning objectives correlated with knowing role in meeting objectives. At least 40% did not know the students' level assigned on their unit nor their learning objectives. Correlations were found on several student survey items including: (1) staff aware of objectives had input in helping meet objectives; and (2) staff competent in working with students enjoyed teaching. Students consistently identified staff lacked patience and time to work with students. Cronbach [alpha] was calculated on both the student and staff surveys. Adequate internal consistency is indicated by Cronbach [alpha]'s of .7 or above. The Cronbach [alpha] for the staff survey was [alpha] = .65, and that for the student survey was [alpha] = .84.

Conclusions/Interpretations: Study findings suggest staff need education in working with students. Additionally, communication between unit nurses and nursing schools needs improvement.

Implications: Study findings can be used to develop optimal clinical experiences for all involved. Staff needs to remember the image they present to students and that they can have a major impact on the students' learning experience.

Outcomes of a Clinical Nurse Specialist-Led Oral Care Study to Improve Hospital-Acquired Pneumonia Events in Acute, Nonintubated, Neurologically Impaired Patients at a Canadian Trauma Center

Robertson T, Carter D, Fraser Health, New Westminster, British Columbia

Purpose: The purpose of this study was to test the efficacy of an evidence-informed, oral care nursing protocol in reducing hospital-acquired pneumonia (HAP) events in nonintubated, care dependent, neurologically impaired, adult patients on an acute neurosurgical unit outside of the critical care environment.

Significance: Current standards of practice for oral care on the neurosurgical unit are variable, have not progressed with the literature, and are suboptimal. An enhanced, evidence-informed protocol would decrease the incidence of HAP and improve the quality of care.

Design/Background: Hospital-acquired pneumonia is a common nosocomial infection and a significant cause of morbidity and mortality, leading to increased length of stay, increased costs, and decreased quality of life. The acute, care dependent, neurologically-impaired population is susceptible to acquiring HAP due to an increased risk of oral colonization, decreased cognitive status, impaired swallow and cough, immobility, and dependency on care. Research on improved oral hygiene in the acute, care dependent neurosurgical population has been limited to critical care units. Current standard of oral care practices on medical/surgical neurosurgical units are variable. Estimated costs associated with HAP in surgical patients is reported to exceed $27 000.00.

Methods: This quasi-experimental, time series study compares retrospective (February-August 2010) and prospective data (February-August 2012) on the rates of HAP, for similar care dependent patients on a neurosurgical unit. The study controlled for primary diagnosis, care dependency and criterion for HAP. An evidence-informed oral care protocol was defined and implemented in the prospective study period. The protocol included elevated head of the bed for mouth care, regular mouth inspections, cleansing, and moisturizing, and consistent nursing documentation. The rate of HAP in the experimental group receiving an enhanced oral care protocol (n =32) were compared with the retrospective group who received standard care (n = 51).

Outcomes: The rates of HAP in the experimental group were significantly less than the control group. The rate of HAP decreased from 24% to 6% in the experimental group receiving the enhanced protocol. It is estimated that the oral care protocol in this study prevented 6 cases of HAP and averting considerable healthcare expenditures.

Conclusions: This study demonstrated identifying high-risk populations and implementing the enhanced oral care protocol was beneficial to improving oral hygiene, reducing incidences of HAP, and improving the overall health of care dependant neurosurgical patients.

Implications: Nurses play a vital role in identifying vulnerable patients and implementing regular oral care regimes in the prevention of HAP. Nurses need to be aware of the connection between oral bacteria in precipitating HAP, and the importance of diligent oral care. Foundational practices such as regular oral hygiene remain important aspects of nursing care in preventing nosocomial infections, optimizing health and promoting quality patient care.

Patient and Family-Centered Care: A Collaborative Approach to Breast-feeding and Surgery

Watson CH, Collier G, Jamison-Gines J, Riley S, Campbell S, Gill SK, Walter Reed National Military Medical Center, Bethesda, Maryland

Purpose: The patient- and family-centered care (PFCC) model directly involves patients/families as intrinsic players in their healthcare goals and outcomes. The purpose of this abstract is to demonstrate an example of the integral role of clinical nurse specialist (CNS) and specialized nursing in supporting this model of healthcare.

Significance: This case highlights the collaborative role of the CNS coordinating processes among different specialties, and the importance of keeping open dialogue with different departments in regard to what can or cannot be accomplished. A collaborative approach helps doctors, patients and the rest of the healthcare team put into perspective realistic goals as well as opportunities to improve them.

Background: As expert clinicians and clinical leaders, the CNS works collaboratively to ensure a safe patient encounter and facilitate PFCC through effective communication and coordination among multidisciplinary teams, nursing specialist and staff.

Description: A PFCC initiative was implemented through the coordinated efforts of the patient/family, and healthcare team, to include neurosurgery, 4 CNSs across 3 specialties, a lactation consultant, and a perioperative registered nurse. A mother, 9 weeks postpartum, contacted the lactation consultant for a plan to maintain the ability to breast-feed through a planned surgery for a brain tumor. A long procedure leading to delayed milk emptying can lead to complications such as breast engorgement, plugged milkducts and mastitis, further complicated by fluid shifting dueto fluids/medications around surgery. In order for this patient to continue breast-feeding it meant maintaining lactating breast health by preventing breast engorgement during and after surgery. Keeping the patient at the center of discussion enabled open dialogue and consistency of support among different services to facilitate patient's wishes.

Outcome: Breast-feeding went largely uninterrupted throughout the patient's 96-hour stay in the hospital. The patient maintained lactation and was able to continue direct breast-feeding of her infant after discharge from the hospital as desired. Collaboration between CNSs from unique services and by those who delivered specialize nursing care prior to a planned surgical procedure contributed to positive patient and staff outcomes.

Conclusion: This patient-centered initiative required respect for the patient's decision, shared information, family participation, and collaboration. Clinical nurse specialists have a major impact on coordination of processes between nursing specialties, staff and healthcare teams, thus improving communication, enhancing continuity and preparing staff for unique processes of care.

Implications: Lactating women undergoing this level of surgery is uncommon. Therefore, few examples for how to support the patient throughout her hospital stay can be found. No protocol exists for it in our facility. After the patient made her wishes to continue breast-feeding throughout the perioperative period known, outcomes rested on cooperation of the patient and her healthcare team. This process directly impacted care rendered by 5 unique nursing services. For this reason, open communication and clinical discussions prior to her surgery enabled the hospital as a whole to support this patient and her family. Clinical nurse specialists played a pivotal role in interpreting clinical implications and influencing support by their nursing staff in order for the patient to garner consistent support for her desired health outcomes.

Patients Preferences at End of Life

Whitehead PB, Carilion Roanoke Memorial Hospital, Roanoke, Virginia

Research Objectives: (1) Validate the use of the Preferences About Dying and Death (PADD) tool as a prospective assessment of patient preferences. (2) Compare patients' stated preferences to family members' and clinicians' perceptions. (3) Assess similarities and differences regarding end of life (EOL) preferences between patients on oncology and palliative care units and perception of preferences by families and clinicians.

Background/Significance: Palliative care and oncology patients struggle with life altering EOL challenges. Research shows terminal patients experience unrelieved symptoms, and often care is discordant with their wishes for treatment. Communication between providers, patients and caregivers may be poor at EOL. Studies show that fewer than 5% of patients have direct input into decision-making. Family members report they were unaware of patients' wishes. The PADD tool provides a potential format to educe EOL patients' wishes and values and a bridge for communication among patients, caregivers and providers.

Methods: This pilot study was a mixed quasi experimental design to validate the PADD tool as a prospective assessment of patient preferences and to compare patients' stated preferences to family members' and clinicians' perceptions. Audio-recorded interviews using PADD were conducted with patients, family members and nurses from oncology and palliative care nursing units at a tertiary hospital in southwestern Virginia. Each interview of 15 to 20 minutes included semistructured closed and open-ended questions.

Results: A total of 28 interviews were completed, 15 oncology and 13 palliative care. Preliminary results indicate PADD elicited patient preference in 4 of 6 domains with statistically significant Cronbach [alpha] of >=.75 in: symptoms, treatment preferences, whole person and moment of death. Because of the small sample size, no statistical differences were identified between participants from both units.

Conclusion: The PADD is a promising tool to assess patient preferences for care at EOL since clinicians need a practical instrument to educe dying patient preferences. An objective tool can alleviate discomfort by providing structure and consistency. Our pilot study showed clinicians hesitate to initiate these conversations and need a validated instrument.

Implications for Research, Policy, or Practice: Continued validation and modification of the PADD instrument is needed for practical clinical use. Preferences About Dying and Death may be a useful tool to elicit patients' EOL preferences in other chronic diseases.

Planting the Seeds of Change Using a Silent Journal Approach

Parris DA, Oklahoma University Medical Center, Oklahoma City

Purpose: Provide a description of how the CNS can utilize the Silent Journal approach to disseminate information to the bedside nursing staff. Also, describe common reactions to proposed organizational change.

Significance: The culture of a hospital impacts the patient's perception of the care they receive and the staff's satisfaction with their work environment. Innovative practices were needed to introduce the key concepts of a culture of caring to the staff of a large academic medical center.

Design: The clinical nurse specialists collaborated with the shared governance leadership to introduce the Silent Journal Club concept at a Shared Governance Forum. To engage staff participation in this concept, the CNSs designed the first poster. The nursing staff had recently been introduced to the concept of a culture of ownership through a book entitled "The Florence Prescription." These important cultural characteristics were utilized in the design of the poster. No method had been established to evaluate the reaction of the staff to the essential characteristics of a culture of ownership.

Description of Methods: A poster was created to summarize the key characteristics of a culture of ownership. A sticker system was utilized to track staff participation and their attitudes toward these principles changing our organizational culture. The staff was given the opportunity to participate on their unit in an area that they identified. The poster was moved from unit to unit within the hospital, and data were collected from each nursing area. A sticker system was utilized to track participation and the staff's opinion regarding these characteristics changing the organizational culture.

Findings/Outcomes: Nurses appreciated the method in which the concepts were presented and that the poster was brought to their individual units. The level of participation varied greatly between the various nursing units. Approximately 40% of the staff participated in the Silent Journal activity. The opinion of the staff regarding the characteristics of ownership changing the organizational culture had a distribution of 39% yes, 30% no, and 33% not sure.

Conclusions/Interpretations: The silent journal approach can be utilized to increase the awareness of the characteristics of a culture of caring. Working within a Shared Governance Structure, the clinical nurse specialist has the unique opportunity to mentor and role model key behaviors within an organization.

Implications for Practice: The findings of this project correlate with any change initiative in that approximately one-third of the staff are accepting of the change in culture, one-third are skeptical and one-third are resistant to the change. As clinical nurse specialist we can collaborate with the bedside nurse to identify the emotional ties to our current culture and to create a roadmap to the culture of caring that every patient and staff member deserves.

Preventing Bloodstream Infections: a Report of Success and Next Steps in a Statewide Collaborative. California Children's Services-California Children's Hospital Association Neonatal Infection Prevention Project in Association With California Perinatal Quality Collaborative Coalition

Beauman S, CNS Consulting, Bernalillo, New Mexico; Kurtin P, San Diego State University, California; Morrow H, California Department of Health Services, Sacramento; Schulman J, Sacramento, California; Wirtschafter D, David Wirtschafter, Inc, Boca Raton, Florida

Significance: Over a period of several years, a varying number of Community and Regional neonatal intensive care units (NICUs) in California, who provide as many as 16 000 patient days per month, have worked together to implement proven and potentially better practices to decrease central line-associated bloodstream infection (CLABSI). This was accomplished by assessing all positive blood cultures using a standardized protocol to identify opportunities for improvement and sharing these assessments with member hospitals to identify shared problems, challenges and potential interventions. All hospitals involved in the collaborative have a neonatal clinical nurse specialist who was pivotal in implementing change and sustaining gains. Leadership and team work were found to be significant predictors of improvement in infection rates.

Design: This project was designed as an evidence-based practice project to implement best practices utilizing test of change cycles when research-based evidence was not available. This approach led to creation and implementation of a "bundle" of practices.

Methods: Bundle elements identified were both related to central line insertion and maintenance. In addition, administrative support and teamwork were a focus of the project. The bundle elements were implemented in the various member NICUs. Deidentified monthly data were submitted to a central repository, and monthly conference calls were held to share experiences and progress. Face-to-face meetings were held 3 times per year. Several factors were found to be independent predictors of outcome, both positive and negative. Specific positive predictors of improved rates were patient volume, leadership rounding, and low birth weight (<750 g). Negative predictors of outcome were perception of line entry auditing value and birth weight >2500 g. Individual episodes of bloodstream infection (BSI and CLABSI) were reviewed in a process referred to as a mini-root-cause analysis. This served to identify specific practices that may have contributed, either refining the "bundle," the individual practices in the specific site, or finally, leading to further practices that may impact BSI episodes.

Outcomes: Best practices and evidence-based practices, where available, were implemented throughout member NICUs following discussion and consensus building. Central line-associated bloodstream infection (rates fell 85% from baseline of 4.2 CLABSIs/1000 line-days (LD) to 0.65 CLABSI/1000 LD. At about the third year of the project, all bloodstream infections (BSI) were reported and evaluated.

Conclusions: While CLABSI rates have improved dramatically, the rate of BSI unrelated to CLABSI remains unchanged over the 2009 to 2011 time period with a mean of 0.55/1000 patient days. The focus has now shifted to improving identified sources of these additional BSIs and implementing potentially better practices for additional improvement.

Implications: This project has shown that improvement in CLABSI in a high-risk population to a previously unimaginable level is possible. The areas of focus currently are feeding advancement/feeding tube care and skin care practices, specifically punctures and breakdown. These areas have little research-based evidence to support practices specific to the neonatal population.

Project RED-CHF: A Reengineered Discharge Quality Improvement Project

Zembles S, St Mary's Medical Center, Blue Springs, Missouri

Purpose: This evidence-based pilot project is based on the 11 key components aimed at preventing readmission with CHF patients developed by Brian Jack, MD, Boston University Medical Center. The purpose of this project is to reduce the hospital readmission rates among the CHF population over a 1-year period.

Significance: Patients with CHF are frequently readmitted within 30 days of discharge. The national average for CHF readmissions is 20 percent with the readmission rate at trial hospital of 19 percent prior to this quality improvement project. Hospitals with high readmission rates will be penalized by Centers for Medicare & Medicaid Services (CMS) reimbursement. Hospitals that can prevent readmissions will potentially save significant healthcare dollars and reduce operational costs.

Design: The CHF population was determined to have the highest readmission rate among chronic diseases at the trial hospital. This population was also identified as high priority by the CMS readmission penalty.

Methods: During the trial, a multidisciplinary team formed, goals identified, roles and responsibilities established. The CNS lead discharge advocate locates patient; communicates with multidisciplinary team; provides information on the disease process of CHF, prevention strategies, early warning signs of exacerbation, actions to take early prior to needing hospitalization, the importance of tracking daily body weight to include providing scales to patients who need one, and medication reconciliation; coordinates discharge plan; and completes a follow-up phone call 2 days postdischarge.

Outcomes: During a 3 month period at the trial hospital (Sep 1 through Nov 31 2010) readmission rates within 30 days had dropped from 19% to ZERO. This program was implemented on a permanent basis (effective July 1, 2011) for all CHF patients. As of 1 June 2012, readmission rates for CHF over 1 year had been maintained at an average of 6.7%. One preventable readmission is estimated to save the trial hospital $37 000 (average length of stay is 7.2 days at $5200 per day). This reduction in readmissions over the course of 1 year will potentially save $750 000 in nonpayment when CMS penalties are fully implemented.

Conclusions: During the trial and permanent phase of the practice change, CHF patients received additional interventions and were empowered to more effectively manage their chronic illness. The 1 year readmission data supports this initiative as effective when comparing the preintervention and postintervention data.

Implications: Success that is seen with the CHF population at the trial hospital is encouraging and is likely to encourage a similar practice change with other CMS high priority chronic diseases that also have high readmission rates such as MI, pneumonia, COPD, hypertension, and diabetes.

Pull Out the "Tool Box": CNS-Led Innovation in Pain Management

Campbell MA, Columbus Regional Hospital, Indiana

Significance: The control of pain among hospitalized patients has emerged as a significant challenge in patient care. Optimizing pain management supports the patient's comfort and well-being which promotes healing. With the aging of the general population pain management is often complicated by chronic pain. In the new world of "pay for performance," pain control is used as a quality indicator and represents an important source of patient satisfaction and reimbursement.

Background: A hospital-wide pain management team lead by the CNS designed a systematic approach to improve pain management in the facility. The team which was multidisciplinary included staff nurses from all areas in the hospital, a hospitalist, pharmacist, pain psychologist, and nurse educators. The complex nature of pain management calls for a multifaceted approach to improve outcomes. A strategy was developed to provide an approach which involved the patient as a participant in their pain management using guidelines from the American Pain Society. The clinical nurse specialist developed a 3 prong approach to pain management. The team then developed the specific interventions of the plan. The strategy was called the "Pain Toolbox."

Methods: The Pain Toolbox consisted of 3 parts; patient education, nonpharmacological interventions and a medical pain order set. The team divided into 3 subcommittees each using the latest clinical evidence to develop their part of the toolbox. The subcommittees developed a 1 page, colorful patient education tool, a "comfort menu" of nonpharmacological interventions and a comprehensive pain order set. After a pilot study on a busy medical-surgical unit, education was developed for nurses and support staff, the interventions went house-wide. The tool box gives the care provider alternatives to decrease pain and increase comfort while the patient is hospitalized. Empowering the patient in treatment decisions gives control back to the patient. With the initiation of hourly rounding the care team now has comprehensive pain management support for their patients using the new tools.

Outcomes: HCAHP scores are a measurement of patient's perception of how well their pain was managed. The pain scores are 1 part of the patient satisfaction indicator which is used by Centers for Medicare & Medicaid Services for reimbursement. The pain score is a composite of the 2 questions concerning how well the patient's pain was controlled and if staff did everything they could do to control the patient's pain. The percentile measurement is the comparative of all hospital's "Top Box" scores. Top Box is computed on the "always" response to the 2 pain questions. For the year 2011 the facility's percentile scores were 31. After the full implementation of the Tool Box, the 2012 year to date percentile score is 89. The organizational goal is to increase these percentile scores to the 90th percentile.

Conclusions: Pain management is challenging. Using a clinical nurse specialist utilizing CNS competencies can design and lead practice change to improve patient care.

Implications: A CNS-led, systematic approach including nurse sensitive interventions and collaboration with medical management can improve pain management outcomes.

The Purple Crusader: Clinical Nurse Specialist Role in Increasing the Core Measure for Stroke Education

Haxton ME, Oklahoma University Medical Center, Oklahoma City

Purpose: Nurses were failing to recognize the basic stroke syndromes, the significance of the different diagnoses and the varying needs of the stroke patient. To improve stroke education, the CNS created (a unique personality) the Purple Crusader to highlight stroke education awareness.

Significance: Oklahoma University Medical Center is a Joint Commission (JC) certified Primary Stroke Center, based on 8 core measures. Education is a difficult core measure to capture and sustain above the acceptable level defined by the JC as greater than 85%. In 2012, a new level of certification, Comprehensive Stroke Center Certification was introduced having higher standards of care for the most critical stroke patients. In preparation for this certification, the hospital raised their standard from 85% to 90%. To aid the nursing staff, a champion was introduced to bring stroke education and recognition to the forefront.

Background: Prior to the arrival of a CNS, the JC core measure for stroke education was averaging fifty to 75% in the monthly reports. Nurses were failing to document on a consistent basis verbal or written education given, topics covered, or time of education. Emergency room charting in T systems and staff nurse charting in meditech did not communicate adding another documentation issue.

Description: Purple is the National Stroke Association's color for stroke and was chosen to represent the push on education scores above the recommended level. To stress the awareness and importance of this issue, the CNS dressed in a purple wig and purple scrubs with key stroke terms printed in white. To show management support, she was pictured in the hospital news paper with the chief executive officer, chief nursing officer, and all associate chief nursing officers. For a month, the Purple Educator went floor to floor doing individual education to identifying stroke syndromes and educating nurses to advocate for the patients' rights for rehabilitation back into society. The Purple Crusader designed an education box for each floor of the hospital based on the level of neurology experience of the nurses. This box contained all written education needed for the 3 major stroke diagnoses and is kept up to date by the CNS with the current evidence-based practice education materials. Purple education sheets were built defining educational needs for each individual stroke patient. Whenever stroke orders were implemented, documentation was linked so that a stroke intervention on both charting systems would be automatically required.

Outcome: The third quarter of 2012, documentation of stroke core measure for education was maintained above 87% with 2 months being reported above ninety percent. Nursing charting of education measures is recognized as the key factor for this improvement.

Conclusions: The unique delivery method of this education has set up the facility in an excellent position for Comprehensive Stroke Certification.

Implications: The Purple Crusader, using the spheres of influence presented a method of improving core measures that was fun and unique and improved education outcomes.

Quantum Leap: Oh Boy! Influencing Patient Throughput

Seemann SL, Bryan Health, Lincoln, Nebraska

Purpose: To describe the clinical nurse specialist (CNS) role in providing clinical quality leadership for influencing systems and processes enabling the timely movement of the emergency department (ED) patient to an inpatient unit.

Significance: From 1999 through 2009, the number of visits to emergency departments increased 32% (NCHS Brief, August 2012). Prolonged ED wait times and increased length of visit time is linked to reduced quality of care, increased adverse events and decreased patient satisfaction (Horwitz et al, 2010) ED crowding in the United States has become so severe that the Institute of Medicine calls it a "national epidemic." To achieve improvement, hospitals need to change a wide range of institutional practices.

Background: Today's EDs are faced with overcrowding and high resource demands leading to significant problems such as ambulance diversions, extended and prolonged patient waiting times, delays in care and poor patient outcomes. Improving performance related to the throughput for the admitted ED patient to the inpatient unit impacts the quality of care for all ED patients. The CNS serving as a quality leader and implementation expert can drive organizational performance by eliminating system barrier.

Description: The ED implemented an advanced admission notice initiative called the "5 Minute Bed Decision." The ED provider utilizes his/her clinical knowledge and experience to provide early identification of an ED patient needing to be admitted. This allows the organization to start mobilizing resources to preplan for the admission. The ability to mobilize resources involved significant collaboration with administration, hospitalists, and inpatient areas to identify innovative options to support patient throughput. Strategies included addressing output factors such as inpatient occupancy, staffing plans, housekeeping practices, admitting processes, and prioritization of non-ED admissions.

Outcomes: The organization has made changes in systems and processes related to these output factors impacting patient throughput. The initiative continues to be enhanced and expanded due to early successes. There is increased collaboration and shared responsibility for ED patient placement. There is improved planning and preparation for an admission. Data demonstrates a decrease in admission delays. Delays related to "Waiting for a nurse" decreased from 93 to 23 occurrences with the initiative. Delays related to "Waiting for an inpatient bed" decreased from 52 to 8 occurrences with the initiative.

Conclusions/Interpretations: Emergency department visits will continue to increase as will the increasing patient acuity even in the face of healthcare reform. Emergency departments are overwhelmed and organizations' must address the institutional practices that are systemic barriers to patient throughput. Overwhelmed ED are rushed and unpleasant treatment environments and a potential for poor patient outcomes.

Implications: The clinical nurse specialist is responsible for identifying systems and processes that are barriers to the effective and efficiency delivery of healthcare. The CNS can create and implement workflow strategies, supporting and enhancing the clinician's work environment to optimize patient outcomes and increase clinician satisfaction while benefiting the organization.

Reaching New Heights: CNS Involvement in Improving Outcomes in a Community Pediatric Emergency Network Outreach Program

Gosdin AM, Tidwell J, Children's Medical Center, Dallas, Texas

Purpose: The CNS is an expanded nursing role with endless possibilities. The purpose of this presentation is to demonstrate CNS impact on education, consultation and outreach services in a hospital network and community outreach program.

Significance: Utilization of a CNS in outreach and education programs can have a positive impact on patient care in the community at a network/system level.

Background: In a large urban area adult healthcare facilities transfer over 4000 pediatric patients a year to local children's hospitals due to lack of knowledge and reported anxiety about care of pediatric patients. Ambulance transport and admission at 2 different hospitals increases costs and use of resources for the patient, family and healthcare facility. In 2005, the Pediatric Emergency Services Network (PESN) began as a special project including local not-for-profit hospitals to support the development of a world-class pediatric emergency services network for local area. Pediatric Emergency Services Network is led and coordinated by a local children's hospital. The mission of PESN is to enhance pediatric triage capabilities and provide ongoing training to emergency personnel in the community. In 2011, the CNS role was implemented to assist with meeting this mission. Pediatric Emergency Services Network provides regular educational offerings on pediatric emergency care at quarterly education events and an annual conference on pediatric emergency care. Pediatric Emergency Services Network also meets with outside hospitals and EMS to provide lectures and consultation services.

Description: Role of PESN CNS: consultant for community pediatric healthcare issues, educator to hospitals and EMS about pediatric professional care guidelines, collaborate with community multidisciplinary healthcare teams, implement evidence-based interventions to improve outcomes, improve outcomes by monitoring quality indicators and facilitating communication, build healthy communities through development of proactive health management strategies for specific health populations.

Outcomes: First-year accomplishments of PESN CNS: increased the percentage of outreach delivered to 5 hospitals outside the urban area as well as local community clinics and EMS providers, assisted the pediatric transport team with community outreach/networking and providing lectures on pediatric emergency care, increased average attendance at quarterly education offerings from 19 to 60 participants, increased education related to emergency care inside the local children's hospital, participated in clinical practice guidelines development to share with area hospitals, assisted hospitals and EMS with obtaining pediatric educational resources related to pediatric emergency care and transport, provided hospitals and EMS with information on pediatric competency training and guidelines for pediatric emergency care based on professional guidelines, assisted organization with development of guidelines for population-based care.

Conclusion: The PESN has uniquely utilized the CNS to disseminate education related to the care of children to nonpediatric hospitals and emergency healthcare personnel in the community. This has had a positive impact on establishing collaborative relationships with local healthcare facilities and will likely contribute to reduction of cost.

Implications for Practice: The PESN CNS is a nontraditional CNS role which can impact the healthcare system and community.

Red Means Stop! Decreasing an Inpatient Fall Rate With an Innovative Traffic-Light Protocol and Focused Staff Education

Rainford M, Hospital of the University of Pennsylvania, Philadelphia

Purpose: To reduce the fall rate on a 28-bed inpatient orthopedic/trauma unit, an innovative strategy utilizing variable alert levels with identified level appropriate interventions was implemented in conjunction with staff education to decrease variance in fall risk identification.

Significance: Creating sustainable improvements in nursing sensitive measures requires consistent surveillance and monitoring for systemic changes that may impact practice and patient outcome. Historically, the baseline fall rate for this unit was above the 50th percentile nationally. Successful implementation of evidence-based practices had reduced falls on this unit to below the 50th percentile in the past year; however, falls were still occurring and the rate increased after implementation of an electronic medical record (EMAR).

Background/Rationale: The hospital transitioned from paper charting to an EMAR requiring significant changes in workflow and documentation standards. The new system contained a electronic falls risk-screening tool previously unknown to the organization. End-user training support focused on ability to navigate the overall structure of the new documentation database. As a result, minimal education focused on the newly integrated falls risk-screening tool. This knowledge deficit contributed to staff failure to appreciate each falls risk identifiers' importance (ie, depression history, male gender), and documentation and fall prevention implementation became variable. There was no longer a risk threshold with the new screen, and inappropriate patients were placed on falls precautions. The hospital's fall risk signs therefore became meaningless.

Description: A traffic-light protocol was developed to instruct nurses when it was appropriate to place a patient on falls precautions, as well as concurrent interventions to implement for low, moderate, or high precautions. Yellow and red circles were created to visually alert interdisciplinary staff of patients at a moderate or high risk of falling, respectively. A staff education poster was created. It provided rationales for each risk identifier, communicating significance to staff. The significance of nursing judgment for fall prevention placement was highlighted throughout the poster and protocol. Also, the protocol called for staff to assess patient cognition to determine fall risk, cognitive status was outlined on the poster to assist staff in deciphering severity of impairment.

Outcome: Prior to implementation of the EMAR, the unit quarterly fall rate was below the 50th percentile nationally; after EMAR implementation, the fall rate rose above the national median within 1 quarter and sustained that increase. Six months after the implementation of the traffic-light protocol and staff education, the unit's fall rate decreased back below the 50th percentile and has sustained at this lower rate.

Interpretation/Conclusion: The creation of a traffic-light protocol, and focused staff education to decrease variance of fall risk identification, can create a sustained lowered inpatient fall rate on an acute care unit.

Implications for Practice: Sustainable changes in patient safety require consistent surveillance; the CNS is best prepared to conduct this evaluation and guide further changes.

Reducing Mislabeled and Unlabeled Specimens

Kitchens JL, Rees E, Arebun J, Johnson L, Vian N, Russel-Morris P, Tzeggai T, Wishard Health Services, Indianapolis, Indiana.

Purpose: The purpose was to reduce mislabeled/unlabeled lab and microbiology specimens by implementing EBP interventions on medical-surgical/telemetry units and to better identify barriers to compliance with hospital policy.

Significance: Correct specimen labeling is critical to patient safety. Mislabeled specimens can delay diagnosis/treatment and increase cost/length of hospital stay. Redraws lead to patient discomfort, and dissatisfaction. Hospital policy requires use of 2 patient identifiers during specimen collection and labeling specimens in the presence of the patient. Collection of specimens from the wrong patient and inappropriate/lack of specimen labeling can occur if proper lab draw procedure is not followed. The average monthly mislabeled/unlabeled specimens in the combined medical-surgical/telemetry units are 49 (2011, YTD). While bar-code scanning during specimen collection is a proven strategy in the literature to reduce mislabeled/unlabeled specimens, this approach was not possible due to time/resource constraints. Less is known about the potential causes of identification errors from a staff perspective including compliance with and barriers to adhering to hospital policy. Understanding reasons for staff deviating from specimen labeling policy is crucial in order to address this issue by designing interventions and allows staff involvement in reducing errors.

Design: A descriptive nonexperimental design was used.

Methods: A CNS-led multidisciplinary team consisting of staff nurses champions and lab personnel collaborated to implement this mislabeled/unlabeled specimen project. Interventions consisted of developing unit champions, creating and posting 2 educational posters with proper lab draw procedure, posting monthly results and compelling stories about the dangers of lab draw errors, roving in-services, reminder signs at the lab tube station and nurses' stations using a team-designed reminder slogan. A 16-item survey was administered to staff to assess compliance with and barriers to adherence with hospital policy to target further interventions.

Findings: Average monthly mislabeled/unlabeled specimens were significantly reduced in the combined medical-surgical/telemetry units after 6 months. Seventy-nine of 130 eligible staff completed the survey. The most noncompliant item self-reported was not labeling specimens at the bedside. Identified barriers to labeling specimens at the bedside included: labels not available, need to reprint labels, wrong label, time needed to find labels. Identified barriers to brining the lab requisition to the bedside included: unable to locate requisition, requisition did not print, wrong requisition, the requisition did not print. Of the staff who participated, 84% were able to correctly answer all knowledge statements about mislabeled and unlabeled specimens.

Conclusions: The interventions utilized were successful at reducing mislabeled and unlabeled specimens in the combined medical-surgical/telemetry units at this hospital system. The interventions utilized should be implemented in other units in the hospital system.

Implications: Staff should be involved in the process of reducing mislabeled and unlabeled specimens. Future interventions include implementing bag label checklists as a reminder of proper lab draw procedure. Future plans include addressing identified preventable barriers to following proper lab draw procedure and providing additional staff education about labeling the specimen at the bedside.

RN Orientation: An Innovative Approach to the Onboarding Process

Opper K, Froedtert Hospital, Elkhorn, Wisconsin

Purpose: The new Nurse Onboarding process as a part of hospital orientation can be costly, long and complex. The purpose of this poster presentation is to describe the methods used by a CNS to improve the RN onboarding process. The role of the CNS in making hospital wide changes will be described.

Significance: Changes in healthcare have prompted a need to improve efficiencies, cost, and outcomes in hospitals. Current state at this hospital revealed that stakeholders were dissatisfied with the onboarding process because of significant variability in orientation practices, and a delay in achieving expected level of productivity by both orientees and preceptors. There were also significant variances in the orientation budget.

Design: A quality improvement project was designed to create a standardized approach for nursing onboarding process for all RNs and graduate nurses (GNs) hired into a Staff Nurse position at the hospital. The goals of the project were to enhance orientee and preceptor satisfaction, increase the efficiency and reduce orientation costs of the overall process. Benner's Novice-to-Expert, ACCN Synergy, and Tanner's Clinical Judgment theoretical models were used to provide the foundation for the onboarding process.

Methods: This project was designed with a collaborative approach between the CNS and Educators. Change management was achieved utilizing Six Sigma methodologies. Surveys and sensing sessions were conducted. Phases of orientation included a didactic classroom orientation, unit based orientation, Nurse Residency for GNs, and a 6 month posthire mentorship. Tools that were developed included: (1) a Competency Outcome Performance Assessment Plan based on Benner's and American Association of Critical-Care Nurses Synergy models; (2) reflective journaling assignments based on Tanner's Clinical Judgment; and (3) a Nursing onboarding tool kit to help guide the Nurse Educators through the orientation process. The new process was implemented on medical/surgical units and expanded to critical care areas and the birthing center.

Outcomes: A more efficient and effective hospital RN onboarding process resulted in increased orientee, preceptor, and nurse leader satisfaction. There has been a decrease in total orientation costs.

Conclusion: Clinical nurse specialists are key as partners in hospital process improvements. Utilizing evidence-based tools, change management methodology, and integrative approaches may lead to enhancements in outcomes, cost reduction, and improved efficiencies.

Implications: Clinical nurse specialists are imperative to process improvement teams. Our competencies in collaboration, of best practices utilization in the orientation of Nurses can influence outcomes with patients, staff, and the hospital.

Role of the Clinical Nurse Specialist in Bringing Evidence to the Bedside

Kaminski G, Lakeland Regional Medical Center, Mulberry, Florida

Purpose: The purpose of this abstract is to describe the clinical nurse specialist's (CNS's) role in operationalizing best practice related to prevention of oral complications in patients with cancer in the community hospital setting.

Significance: The CNS role is key to improving nursing practice, ensuring that patient care is based on best research evidence, clinical expertise, and patient values and preferences.

Design: Plan-decrease oral complications in patients receiving chemotherapy and in neutropenic patients. Do-collaborate with pharmacy and infection control to obtain QI data, related to epidemiology; complete literature review and analyze results; develop an oral care survey for the patients; recruit support from all disciplines involved in direct patient care for data collection and teach-back prior to patient discharge. Study-review baseline data related to patients who develop oral complications vs those who do not. Act-trial the patient survey; mentor staff to embrace the power they have in influencing positive patient outcomes!

Methods: Each specialty unit within the community hospital has a unit based council (UBC) that considers patient-sensitive indicators of best practice and recommends practice changes/enhancements to the unit leadership. The CNS, as facilitator within the UBC, brought this project opportunity to the council as an aspect of patient care that needed attention. A review of literature was performed and results were shared with the UBC. The proposed plan was double-pronged: patients' understanding of oral care would need to be assessed and staff understanding of the importance of oral care would need to be reinforced. The manager ensured that all direct care staff received information related to importance of oral care. The UBC designed posters for patient rooms, with clocks to assist the patient to remember when to perform the next oral care. Evaluation of outcomes were measured 2 months after implementation of the campaign.

Outcomes: At baseline, thirty chemotherapy patients and thirty neutropenic patients were surveyed about oral care practices; only 75% of each sample had an adequate understanding of proper oral care. Two months after implementation, 92% of patients could verbalize proper care and 100% had oral care at the bedside when asked (n = 60; 35 chemotherapy patients and 25 neutropenia patients). Prior to implementing the project, 103 patients had Grade 2 or 3 stomatitis and 76 of these were related to chemotherapy and/or neutropenia (n = 455 patient admissions). After implementing, 118 patients had oral complications, but only 28 cases were in patients who received chemotherapy and/or had been neutropenic (n = 512 patient admissions). Other factors related to patients with stomatitis were identified.

Conclusions: Breaking a project into small tasks made it easy to accomplish. By accepting ownership of the performance and outcomes, not only was this a successful project, but continues to be sustained 2 years out from implementation. Bringing evidence-based practice to the bedside not only empowered our patients to have some control over their care-it changed patient outcomes.

Implications: Mentoring staff in development of evidence-based practice skills reduces the mystical quality of research, thus encouraging best practice by the multidisciplinary team in the community hospital setting.

Role of the Clinical Nurse Specialist: Conceptualization, Development, Implementation, and Adoption of Computerized Decision Support Technology in the Critical Care Environment

Serio-Melvin ML, Mann-Salinas E, Mittelsteadt P, Robbins J, Salinas J, Shingleton S, Fort Sam Houston, Texas

Purpose: Describe the clinical nurse specialist's (CNS's) role in conceptualizing, developing, implementing and adopting computerized decision support technologies in the critical care environment.

Significance: Advances in computer technology have impacted healthcare delivery through the development of electronic health records, advanced medical devices, improved imaging, and diagnostic tests. However, these advancements have generated large data silos that make timely clinical decisions difficult.

Background: Computerized decision support systems (CDSS) have been hypothesized to improve patient care by helping providers make clinical decisions using advanced information technology approaches. This includes adding the ability to make decisions based on large and complex data sets, graphically displaying real-time data or by alerting clinicians of a change in patient status, thus improving situational awareness. However, the engineering teams who develop these technologies often do not understand how clinicians need to prioritize or how hospital systems work. This results in technologies that may not meet the users' needs and are difficult to implement and adopt.

Description of Methods: A CNS recently changed roles and became an integral member of a research team that develops CDSS technologies. This individual collaborates with a diverse, multidisciplinary team of research scientists, clinicians and biomedical software engineers. In this role, all 3 spheres of CNS influence are impacted by serving as a consultant, liaison, coordinator, educator, and researcher. Using a transformational leadership style and a bi-directional communication feedback methodology, the CNS serves as an information conduit between the clinicians and engineers. This collaboration results in the implementation of innovative technologies that integrate complex scientific concepts with bedside clinical requirements. To maintain familiarity and influence with the clinical staff, the CNS is readily accessible, consults with other CNSs and frequently participates in patient care rounds. To promulgate software adoption, the CNS frequently teaches the staff how to utilize the CDSS technologies to improve patient care. The CNS also disseminates the information gained by analyzing the data generated from several software technologies and presents this information to the clinical staff and at national conferences.

Outcomes: At our hospital, we have developed ten CDSS technologies that assist with the various clinical issues such as burn resuscitation, wound mapping, ventilator management, nutrition optimization, a patient care checklist and task list, and a provider alert system. These technologies are in different stages of development, implementation and adoption.

Conclusions: In direct coordination with biomedical software engineers, a CNS who is a clinical expert in that patient population, familiar with the clinical staff, who also has significant communication, research and leadership experience, provides a critical resource for successful conceptualization, development, implementation and adoption of CDSS technologies in the critical care environment.

Implications: A CNS with knowledge in advanced information technology has the skills to effectively represent the interests of the clinical staff during the conceptualization and development of computer decision support technologies resulting in successful implementation and adoption.

The Role of the Clinical Nurse Specialist in Reducing National Central Line-Associated Bloodstream Infection Rates

Sawyer M, Wyskiel R, Johns Hopkins Hospital, Baltimore, Maryland

Purpose: Describe the role and impact of clinical nurse specialists in leading national improvement projects.

Significance: Central line-associated bloodstream infections (CLABSIs) are common, costly, and lethal. Although hospitals have put tremendous effort and resources to reduce these infections there has not been a successful scalable framework to reduce these infections nationally.

Background/Rationale: Numerous studies, including large-scale, statewide collaboratives, have shown that CLABSIs are preventable. Yet in spite of strong evidence, patients still die every year in the United States as a result of these infections. This study was designed to test the scalability of a state-wide collaborative to the national level.

Methods: We conducted a prospective, collaborative cohort study from May 2009 to September 2012. This multifaceted intervention included evidence-based interventions to reduce CLABSIs and the implementation of a Comprehensive Unit-Based Safety Program (CUSP) in each clinical unit. The CUSP program was an intervention to improve safety culture. Participating hospitals in each state were coordinated through their state hospital associations. The national project team, including a clinical nurse specialist, led 6 cohorts of states over the 3-year period. Each state was assigned 2 national project leaders to coach the teams through the program. At the national level, the CNS led all nursing-related interventions, coached on the CUSP program, and was assigned as project lead to 8 states. Baseline CLABSI data were submitted for the 12 months prior to the start of the study. Teams submitted monthly central line infections and patient days for 2 years after the start of the project and were able to obtain real-time comparisons with participating hospitals in their state, cohort, and nationally.

Outcomes: There were 1821 clinical units from 1081 unique hospitals across 44 states, the District of Columbia, and Puerto Rico, who enrolled in this study. Of these 1292 (77%) were adult intensive care units, 442 (24%) were non-intensive units, and 85 (5%) were pediatric units. Participating ICUs compromised 30% of all ICUs nationally. The average total bed size was 254 (SD, 229). Units that formally withdrew and units that never submitted any postbaseline data were excluded in the analysis (n = 47). Among participating adult ICUs, CLABSI rates decreased from 1.903 infections per 1000 central line days at baseline to 1.137 infections per 1000 central line days, an overall relative risk reduction of 40%.

Conclusions: Assuming baseline rates had remained the same, this project resulted in an estimated 2110 to 2452 prevented CLABSIs. Given a 12-25% mortality rate associated with these infections this project potentially eliminated 294-613 deaths. Finally, with the literature reporting the average CLABSI costing $70 696 in 2012 dollars with a 2 standard deviation range of $36 666 to $97 234 this project may have averted $89 909 566 to $238 426 030.

Implications: This project provides a roadmap for the United States to save patient lives and reduce healthcare costs. Clinical nurse specialists have a key role in leading these national initiatives.

Safe Passage

Allen S, Cox M, Children's Medical Center, Dallas, Texas

Purpose/Objectives: The purpose of this presentation is to describe the role of the CNS in creating a safe patient environment in the midst of an inpatient relocation.

Significance: Today's healthcare environment demands flexibility and frequent repositioning. To better utilize space, our pediatric inpatient facility relocated the endocrine inpatient population to a new area. This presentation describes the CNS role and response to the staff education needs, staff emotional needs, staff competencies and ongoing support required for this transition.

Background/Rationale: Schoolfield and Orduna, 1994 (Understanding Staff Nurse Responses to Change: Utilization of a Grief-Change Framework to Facilitate Innovation) identified the Grief-Change Framework that helped to predict and identify our staffs' response to change. This framework was helpful as staff worked through the relocation and changes in required competencies.

Methods: The CNS role grew from simply providing expert clinical education to that of a project manager in coordinating multiple services within the facility that played a role in providing patient care. All spheres of influence were utilized by the CNS as a complex relocation and safe care standards were scrutinized.

Outcomes: The patient relocation provided the opportunity to examine best practices as well as practice documents to ensure consistent, safe practice. Clinical Practice Guidelines evolved as a result of the move. Once the patient move was completed, both staff and physician providers were polled as to satisfaction with the patient relocation and the support received. Results of these surveys, and lessons learned will be shared.

Conclusions: Healthcare is delivered in an environment of change: the CNS can be an effective change agent across the spheres of influence.

Implications: As future patient relocations are planned for our ever growing facility, the lessons learned from this event will pave the way for future safe passages for our patients.

Salty Tales of Hyponatremia

Leeper B, Flanders S, Smith SH, Baylor University Medical Center, Dallas, Texas

Significance: Hyponatremia is common in hospitalized patients and has been linked to poor outcomes. Several studies have demonstrated patients with hyponatremia are more likely to be admitted to critical care, have longer lengths of stay and higher mortality rates. Treatment of hyponatremia with fluid restriction or hypertonic saline is not new. The recent introduction of a new class of medications to treat hyponatremia has heightened awareness related to the risk of serious adverse events if close clinical monitoring is not implemented. This represents a major patient safety issue.

Purpose: To provide an example of how a group of CNSs collaborated with a multidisciplinary team to develop order sets/protocols and education for the nursing staff on interventions and assessment of the patient being treated for hyponatremia.

Design: We noticed an increase in the use of hyptertonic saline in our facility as well as the introduction of the vasopressin inhibitor agents (vaptans) in the oral and parenteral forms outside the ICU and within the ICU. A major clinical practice issue was the lack of knowledge by the nursing staff regarding monitoring patient response to the medications resulting in significant adverse events. We also found that various providers were ordering these medications without full knowledge of the effects and close clinical monitoring requirements.

Description of Methods: As a result, the CNSs collaborated with a multidisciplinary team to develop order sets and implemented directives on when a patient receiving these interventions should be admitted to the ICU. We developed clinical practice alerts for the nursing staff and conducted nursing grand rounds on hyponatremia, pharmacological interventions and monitoring requirements. Case exemplars with an audience response system were used to demonstrate key points. Education has focused on accurate monitoring of the urine output and laboratory tests (urine osmolality, serum sodium levels) with specifics of when to notify the physician. Education also stressed the importance of neuroassessments and looking for subtle signs of heart failure (respiratory rate, pulmonary status, etc).

Findings/Outcomes: The order sets specify provider use and mandate patient transfer to the ICU if the parenteral form of a "vaptan" or hypertonic saline is being ordered. We have found improved provider compliance with use of the order sets. Nursing staff have a heightened awareness of the monitoring requirements for patients receiving these medications as evidenced by the questions from the staff when one of the medications is ordered (example: does this patient need to go to the ICU, etc). There has not been an adverse event reported since the order sets were implemented.

Conclusions/Interpretations: We learned the importance of assuring education of the nursing staff when a high-risk class of medications are introduced to the market and added to our pharmacy formulary. We have a process in place with nursing and key clinical pharmacists to collaborate on this issue.

Implications for Practice: This experience is an example of a response to a series of adverse events related to the occurrence of a common high risk, poorly understood clinical situation and the associated interventions. The lessons learned and interventions used to address the clinical situation can be translated and used for other high-risk situations CNSs encounter every day.

Seamless Patient Care for Nonspecialty Patient Populations

Chambers C, Daron D, Menardie C, Mayo Clinic, Phoenix, Arizona

Purpose: The implementation of a practice improvement change structured by clinical nurse specialist (CNS) leadership toward creating patient care resources to assist nursing staff in providing seamless patient care of nonspecialty patient populations. Develop an effective cross-continuum resource that promotes quality patient transition of care and reduces avoidable harm.

Significance: Bridging the gap of clinical expertise in providing seamless patient care on a nonspecialty unit eg Ortho-surgical patient on a cardiovascular (CV) unit unfamiliar with hip precautions or any necessary equipment.

Design (Background/Rationale): The development of online resources was part of a pilot to provide seamless patient care of nonspecialty patients. These online resources will assist the registered nurse (RN) floating to or for the care for a CV patient placed on a nonspecialty unit due to overflow in managing specific medications (eg, milrinone) and/or postprocedures (eg, pacemaker). The mindfulness of this project has been designed for the RN that does not specialize in CV patient care.

Description of Methods: The seamless patient care project was developed in 3 phases; phase I-identify problem (windshield survey to identify themes), and objectives; phase II-develop resources and template, incorporate institutional policy workflows and approved online resources; phase III-publication of online seamless patient care resources on each individual unit Web link and onto a central online Web-based repository.

Findings/Outcomes: Integration of CNS core competencies within the spheres of influence: Patient/Client Sphere, program of care designed for specific patient populations and transitions of patient/clients are integrated across the continuum of care to decrease fragmentation; nurse and nursing practice sphere, support and empower the nurse to provide safe patient care at the point of service, and increase social networking that encourages porous boundaries; organization/system sphere, remove barriers and facilitate quality of care through innovative improvement of providing safe patient care to the different patient populations across the institution.

Conclusions/Interpretations: The seamless patient care project was developed as a result of need that emphasized the usefulness of the online resource tool. Exemplary teamwork toward a shared vision promoted safe/quality patient care through the 3 spheres of influence of CNS practice that compliments the efforts of a framework to improve patient care and staff satisfaction. Leading change and motivating others is a positive transformation of social networking of which the CNS uses influence to break barriers and encourages creativity.

Implications: Nurse satisfaction played a key role in this project especially with the members on the unit-based practice team that made this project a success. The implementation of unit-specific online patient care resources has been supported and endorsed by nursing executive leadership throughout each inpatient care unit.

Staff Perception of the Value and Efficacy of Multiprofessional Rounding

Tuggle D, Baptist Health, Louisville, Kentucky

Purpose: This pilot project was launched in 1 ICU to develop multiprofessional rounding (MPR) processes satisfactory to team members for future expansion to all hospital ICUs for the improvement of patient outcomes.

Significance: This project is significant for illustrating the role of the CNS in advancing evidence-based practices through a team-based initiative.

Design/Background/Rationale: Patients in the intensive care unit (ICU) have complicated, multisystem dysfunctions and often life-threatening medical conditions. Their management requires skilled communication, comprehensive oversight, and organized management. In light of that, many professional organizations recommend the use of MPR to promote better collaboration and care coordination.

Description of Methods: The project was designed as 3 phases: phase 1) MPR Team Recruitment and Process Development (December 2011-September 2012): a literature review was completed and shared with a project team consisting of representatives from: nursing, pharmacy, respiratory therapy, case management, dietary, infection control, physical therapy, spiritual services, wound/skin, palliative care, and information technology. Physicians/intensivists joined following formal launch of the proposal. Processes for MPR were trialed with daily, informal team feedback and formal monthly assessments with administration until an approach agreeable to all was established. Phase 2) MPR Process Assessment (September 2012): A 10-question, online survey was developed for completion by team members.

Sample: Four ICU day-shift staff including 22 RNs, 2 CNSs, 1 nursing director, 4 intensivists, 2 pharmacist, 1 case management, 1 respiratory therapists, and 1 dietician. Measurement Phases 1 and 2: Survey statements to be responded to as strongly agree, agree, neutral, disagree, strongly disagree, not sure. (1) MPR better facilitates overall plan of care and patient outcome. (2) MPR decreases patient length of stay. (3) MPR better promotes core measures and care bundles. (4) MPR facilitates appropriate medication choices and earlier deescalation of antibiotics, sedatives, and so on. (5) MPR leads to earlier extubations. (6) MPR leads to faster and more appropriate discharge planning. (7) MPR facilitates earlier and more appropriate nutritional support. (8) MPR improves team communication. (9) MPR helps reduce potential for adverse events. (10) MPR provides a forum for advancing clinical knowledge and education.

Data Analysis: Phases 1 and 2: Descriptive statistics will be used to analyze survey data. Phase 3: MPR Outcome Assessment (January 2013): This phase will examine improvements in length of stay, ventilator weaning time, and infection rates. Measurement Phase 3: Recorded data for length of stay, ventilator weaning time and infection rates before and after MPR initiation in this pilot ICU setting. Data Analysis Phase 3: Comparative statistics.

Findings/Outcomes: MPR are believed to provide improved outcomes for patients. The key to successful implementation of MPR is a pragmatic process that assists team members in practicing at their highest level. The results of the Phase 1 and 2 survey will show if the processes developed are meeting this goal. The results of the Phase 3 assessment will indicate whether MPR is making a difference in patient length of stay, ventilator time and infection rates.

Conclusions/Interpretations: To be determined.

Implications: To be determined.

Sweet Kids: Initiating a Diabetes Teen Clinic to Improve Glycemic Control

Cox M, Children's Medical Center, Dallas, Texas

Purpose: The purpose of this poster presentation is to describe the development of an alternative clinic intervention for the adolescent diabetic patient.

Significance: Metabolic control is at risk in the diabetic adolescent due to both increased insulin resistance of puberty and the developmental characteristics of the adolescent.

Design: The poster describes the need for alternative interventions for the adolescent as well as the subsequent development of the Teen Clinic.

Description of Methods: Upon a review of average metabolic control of the adolescent diabetic patient, the CNS identified a need for alternative interventions for this population to promote improved metabolic control. The poster describes the process of developing and implementing the Teen Clinic utilizing developmentally appropriate strategies.

Findings and Outcomes: Results of Nine months of clinic interventions will be presented to include metabolic control and clinic attendance.

Conclusion and interpretations: Routine clinic visits as recommended by the American Diabetes Association help to address insulin requirements, but allow little time for behavioral interventions, and no peer support. Metabolic goals frequently are not met by the adolescent patient as defined by the American Diabetes Association. Alternative intervention strategies should be assessed for efficacy.

Implications: Similar interventions could be used for adolescents with other chronic disease diagnoses.

Taking a Closer Look: Factors That Impact Readmissions in Patients With Heart Failure, Acute Myocardial Infarction, and Pneumonia

Centeno M, Reed J, Baylor Health Care System, Dallas, Texas

Purpose: The purpose of this project was to determine the specific factors that increase or decrease the likelihood of a patient with heart failure, acute myocardial infarction (AMI), or pneumonia being readmitted within 30 days after discharge.

Significance: Across the United States, 30-day hospital readmissions are common and costly. Many of the readmissions may be preventable. While Medicare has implemented penalty for facilities with higher than expected readmission rates for AMI, heart failure (HF), and pneumonia (PNE), the problem is not limited to the Medicare population. The purpose of this project was to determine the specific factors that increase or decrease the likelihood of a patient with HF, AMI, PNE being readmitted within 30 days after discharge.

Background: Substantial evidence indicates that improving processes and transitions across care continuum can reduce avoidable readmissions. However, there may be factors that influence readmissions despite having a good transition. During the readmission, the focus is to treat the patient's condition with the goal of getting the patient ready for discharge, not necessarily addressing the factors that may have caused the readmission.

Methods: From September 2011 to April 2012, patients with HF, AMI, PNE readmitted within 30-days were interviewed by the department of social work and care coordination using a questionnaire. The patients who were discharged in the same time frame but did not readmit were called and interviewed.

Outcomes: As expected, non-readmitted patients demonstrated markedly improved lifestyle modifications in comparison with the readmitted group. In regards to follow-up visits, non-readmitted patients were significantly more likely to see their doctor after they were discharged. Significant differences as they pertain to lifestyle considerations were apparent in the usage of a pillbox and the compliance with a special diet. Non-readmitted patients were more likely to receive discharge phone calls regarding their care and instructions on deep breathing exercises. Both groups exhibited similar rates of difficulty in regards to "getting a follow-up appointment" and "taking medications." The location of discharge after initial hospital stay may indicate a confounding factor that can be attributed to improved discharge health of non-readmitted patients. Limitations to the study include the retrospective design, relatively small sample size, and the reliability of patient responses.

Conclusions: In addition to transitions of care, systems have to be in place to increase access to care providers and improve patient and family's ability to provide self-care. Coordination with community resources is also imperative.

Implications: It takes commitment and teamwork to impact readmissions. Efforts to improve discharge planning, transitions of care and coordination with other resources must be in place for all patients regardless of payer. Incorporate a risk stratification tool to predict risk of readmission to guide the intensity of postdischarge interventions that meet the patient and family's.

Teaching Clinical Nurse Specialist Students to Resolve Conflict: Strategies That Promote Effective Communication and Teamwork

Altmiller G, La Salle University, Philadelphia, Pennsylvania

Purpose: The purpose of this presentation is to discuss strategies to equip clinical nurse specialists to manage conflict and resolve situations where difficult communication creates a challenge to achieving effective outcomes.

Significance: Educators know that there is increasing potential for their advanced practice nursing students to encounter difficult situations, difficult colleagues, and negative behaviors in the workplace. Hierarchal relationships and oppressive communication patterns can distract from a patient-centered focus, negatively affect outcomes, and place patients at risk.

Background/Rationale: The Joint Commission has identified communication as the root cause of many sentinel events and now requires accredited agencies to uphold an appropriate code of conduct and to address disruptive behaviors. Educators of advanced practice nurses are in a unique position to influence both a healthy work environment and a culture of safety by teaching their students strategies that de-escalate aggression and promote communication and teamwork.

Description/Outcome: Using an interactive process, students identified a difficult encounter or situation where conflict impacted patient safety and then retold their story using 1 of 3 communication strategies: (1) cognitive rehearsal, (2) reframing communication using safety strategies, or (3) de-escalation techniques for aggressive behaviors. Through this process, students recognized that they have the ability to develop communication skills that can positively affect outcomes and address safety concerns.

Interpretation/Conclusion: As they transition from student to advanced practice registered nurse and begin the interview process, many graduates will be asked not only about what actions they would take in particular patient care situations, but also about what measures they would take in difficult interactions with colleagues. Educators need to see the value in helping students develop behaviors that promote effective communication and teamwork.

Implications for CNS Basic and Continuing Education: Equipped with knowledge of these strategies, Clinical nurse specialists will have the communication tools needed to influence the care of patients, to provide leadership and support for nurses, and to improve patient care processes and outcomes for the institutions that use them.

TeamSTEPPS + Simulation Drills = A Formula for Nurse Residency Success

Wengier S, Oklahoma University Medical Systems, Norman

Purpose: To provide the nurse resident the opportunity to practice TeamSTEPPS skills/behaviors during high-risk obstetrical simulations to gain proficiency in team knowledge, skills, and attitude competencies.

Significance: Entry into perinatal nursing as a novice nurse is an overwhelming endeavor. Most difficult is to do so in a tertiary, academic setting where there is the frequent opportunity to care for high-risk obstetrical patients. It is imperative that the components of a nurse residency provide the novice nurse the essential skills and tools necessary to practice safely.

Design: The OB clinical educator and the perinatal CNS collaborated to develop a standardized 12-week nurse residency program for present and future nurse residents. The residency program outline consists of a didactic section based on the AWHONN Core Curriculum, the TeamSTEPPS Essentials Course, HeartMath's Revitalizing Care, 24 hours a week of clinical care with a nurse resident coach and obstetrical simulation drills.

Methods: The Perinatal and Pediatric CNSs taught the TeamSTEPPS Essentials Course to the nurse residents. The Perinatal CNS designed and created MRS HOOP (Mobile Real-time Simulator Human Operated Obstetrical Puppet) for use in the simulation drills. Teams of 5 to 6 nurse residents participated in simulation drills specific to the didactic topic for that week. The mobility of MRS HOOP allowed conducting the simulation drills on the obstetrical unit and enabled the nurse residents to become more familiar with the facility layout. The OB clinical educator and the perinatal CNS debriefed the videotaped simulations with the nurse residents. To evaluate the impact of the TeamSTEPPS course, we compared the team's performance using the Teamwork Evaluation of Non-Technical Skills (TENTS). This tool assesses the behaviors that are part of the 4 core constructs of teamwork in TeamSTEPPS-communication, leadership, situation monitoring, and mutual support. In addition, the nurse residents took a written test for assessment of comprehension and application of the core constructs.

Findings/Outcomes: TENTS scores were slightly higher in overall teamwork for the shoulder dystocia drill (4 = observed/good) than the more complicated postpartum hemorrhage drill (2 = observed/marginal). However, overall leadership scores were higher for the postpartum hemorrhage drill (2 = observed/marginal) than the shoulder dystocia drill (1 = observed/poor). The written test was administered 2 months after the TeamSTEPPS Essential Course, 7 residents scored 100% and 4 residents scored 90%. Nurse residents felt safe that they could voice concerns to us regarding process issues identified by them during the drills.

Conclusions: Adding simulation drills to the nurse residency curriculum was for not only skills based training, but also to reinforce and practice/apply the teamwork and communication skills/behavior taught within the TeamSTEPPS course. The simulation drills provide the CNS the opportunity to support and mentor the novice nurse for hands-on practice during this crucial transitional period.

Implications for Practice: Simulation provides the interactive learning method preferred by the new generation of nurses. It is an avenue to identify gaps in the knowledge, skills, and attitudes so crucial to practice safely in the clinical setting.

To the Bedside: Clinical Nurse Specialist Collaboration Among Units to Support and Sustain Bedside Hand-off Report

Krupp A, Van den Berg S, University of Wisconsin Health, Madison

Significance: Communication and patient handoff are 2 processes that are linked to adverse patient events. To prevent this problem, The Joint Commission requires all healthcare providers to "implement a standardized approach to handoff communication including an opportunity to ask and respond to questions" (2006 National Patient Safety Goal 2E). The quality of nurse communication is also important as it relates to patient satisfaction and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results. Bedside report allows for standardized approach to handoff while including the patient and family in their care.

Design (Background/Rationale): Historical RN hand-off report was face-to-face and occurred at workstations on the unit. The transition to RN hand-off report at the patient bedside was accomplished using a unit champion model. Two units within a nursing division (18-bed medical unit and 24-bed medical/surgical/trauma ICU) used similar processes to support change. The medical unit implemented bedside report 6 months prior to ICU implementation. Clinical nurse specialist collaboration among units promoted sharing of ideas and successes. The CNS and champion for the medical unit helped spread and encourage change by presenting their process at the ICU champion meeting.

Description of Methods: Unit nursing staff partnered with nursing leadership to develop a champion group on each unit. A review of literature and unit safety events was used to create urgency with the champion group. Champion groups met regularly for 3 months prior to implementation and postimplementation. Projects included developing the workflow for bedside report and developing staff education. Champions provided 1:1 education to all staff members prior to the implementation date. The CNS and nurse manager co-facilitated meetings and found solutions to barriers. Common barriers included the lack of computers in each patient room, fear of discussing sensitive information with patient and/or family at the bedside, and concern with family interruptions during hand-off report.

Findings/Outcomes: Nurse perceptions of HCAHPS questions and nurse perceptions of bedside report (quality, length of time, standardization) were measured preintervention among both units and will be measured postintervention. The frequency of handoff report occurring at the bedside and feedback from patients and families is routinely assessed with nursing leadership rounds.

Conclusions/Interpretations: Bedside report has been embraced by general medicine and medical-surgical ICU staff, patients, and families. RNs on both units are consistently at the bedside for every hand-off report. While patient acuity and needs were diverse among the 2 units, core elements of RN hand-off are similar and partnering among units was valuable.

Implications for Practice: Bedside report continues to be implemented hospital wide. Nurse leadership collaboration, use of a champion model, and significant prework planning were keys to implementation and sustainability success.

Track and Trigger: Implementing an Early Warning Scoring System in the Intermediate Care Unit

Rose T, US Army, Fort Sam Houston, Texas

Significance: Most rapid response team (RRT) calls are triggered by the observation of abnormal vital signs at a single time point. It is this concept and the confusion of when to call RRT, and the applicability of the established RRT procedures that had the nurses of this Intermediate Care Unit frustrated. Early warning scoring tools score measured vital signs at prescribed intervals and provide an easy, standardized process that allows nurses to recognize patients at risk of deterioration. These tools not only provide an opportunity to identify the need for early intervention, but also reinforce the need of nurses to critically think the patient's condition using the whole patient picture not just one out of range vital sign in a single point in time. Currently, the Institute for Healthcare Improvement is encouraging organizations to investigate and implement early warning scoring systems to guarantee that no at-risk patients are missed. (IHI, 2011)

Rationale: An evidence-based approach was used in an effort to improve nursing satisfaction with an existing RRT program in the intermediate care unit of a level I trauma center by adding a modified early warning scoring tool in an 8-week process improvement project.

Description of Methods: A literature search was conducted and the PAR Scoring tool used by Williams (2011) was selected along with the escalation pathway to guide decisions and interventions in the event of patient deterioration. The staff was initially surveyed to identify their satisfaction of the existing RRT procedures. They were educated on the use of the tool and after the 8-week implementation phase the staff were resurvey on their satisfaction with the tool when used with the existing RRT protocols and applicability to the intermediate care unit (IMCU) patient environment.

Findings/Outcomes: Overall staff satisfaction with this tool was 49%. Several staff members provided verbal feedback discussing the utility of the tool regarding improved critically think. Additionally, staff appreciated the ability to focus on a trend of patient vital signs over a specific period of time, thus providing a clearer picture of when to activate the RRT. Although the scoring tool was not automated, 82% of staff members said it was an easy tool to use. Moreover, 56% of the respondents felt that the tool was applicable to the IMCU environment.

Implications: Utilizing the 3 spheres of influence, the clinical nurse specialist identified a gap in an organizational process; developed and implemented the TnT Scoring Tool to assist the bedside nurse in advancing their practice by focusing on trending each vital sign observation as an overall indicator of the patient's condition and aid in critical decision making with the use of an escalation pathway; and as a byproduct of this intervention, patient outcomes are destined to be improved.

Transforming Attitudes About Death Through the Use of High-Fidelity Simulation

Gilliland I, McNeill J, University of the Incarnate Word, San Antonio, Texas

Significance/Purpose: Educational programs preparing healthcare professionals continue to be deficient in providing end of life care content. This is true for nursing, medicine as well as pharmacy. The purpose of this study was to assess the effect of high-fidelity simulation on students' attitudes and perceived competencies in providing end of life care in a graduate interdisciplinary palliative care course with CNS students and pharmacy students.

Design/Methods: A quasi-experimental design was used to determine the effects of participating in a high-fidelity simulation on students' attitudes and competencies in providing end of life care. Thirty graduate students (CNS and pharmacy) participated in a scenario of the 15 minutes before and 15 minutes after the death of a patient with end stage renal disease. Students completed the Attitudes Towards Death Survey and the End of Life Competency Survey prior to and after the simulation. A reflections journal exercise was used to capture postsimulation subjective reactions, and a course evaluation was used to assess students' satisfaction with the simulation experience.

Findings: Mean presimulation and postsimulation score differences in attitudes towards death and end of life competencies were analyzed using a paired samples t test. There was a significant decrease in mean attitude scores from presimulation (26.5 +/- 3.8) to postsimulation (24.0 +/- 5.9; P = .011) indicating significant improvement in attitude towards death. Mean scores on competency also showed significant changes from presimulation (16.53 +/- 5.7) and postsimulation (24.04 +/- 6.6; P < 0.001) indicating significantly improved self-perceived competency in providing end of life care. Course evaluations indicated they were satisfied with this teaching method (4.6 on a 5-point Likert scale with 5 being the highest satisfaction). They felt the scenario was realistic (4.3), and they had the ability to analyze their own behavior regarding end of life situations (4.4).

Conclusions and Implications for Practice: High-fidelity simulation is an innovative way to challenge students' attitudes and help them with knowledge acquisition about end of life care. This study has suggested a positive impact on students' attitudes about death and their perceived end of life competencies. More research is needed on how to best prepare all health professionals to provide end of life care.

The Transition to the Clinical Nurse Specialist Model: One Hospital's Journey to Success

Weaver S, Pfieffer J, Taylor N, Nemours/AI duPont Hospital for Children, Wilmington, Delaware

Purpose/Significance: Recently our organization transitioned from a unit-based educator model to a population-based CNS model. This change led to a team, whose members had varying levels of experience and academic preparation. Throughout this change process members of the team needed to develop individually within their CNS role while staff and patient needs continued to be a priority. This created unique challenges not only for our CNS team, but also for our patients, nursing staff, and our organization.

Design (Background/Rationale): A reduction in workforce in 2009 led our organization to reevaluate our nursing structure and its impact on patient outcomes. The CNS model was chosen because it allowed for nurses with advanced degrees to provide clinical specialization at the bedside. Our organization had only 2 experienced CNSs' and several unit-based educators. Many of our educators were involved in graduate level education and were offered the opportunity to transition to the role of Nurse Clinician until their education, certification, accreditation, and licensure requirements were met. To complicate matters, several newly minted CNSs' were hired into the role creating more challenges for our group.

Description of Methods: Some of the challenges the new group experienced were a lack of a formal CNS orientation process and pioneering the development of the CNS role in new practice areas. Along with these challenges, our organization as a whole (direct care nurses, physicians, and other interdisciplinary team members) was mostly unfamiliar with the CNS role. To overcome this, we created several poster and podium presentations to educate the organization about this advanced practice role. Our 2 experienced CNSs' developed an orientation checklist which included short, intermediate, and long-term goals based on the 5 CNS subroles. The CNSs' were assigned as mentors to help coach and guide those new to the role through their entry into CNS practice. To streamline, informal weekly CNS meetings were initiated to discuss the orientation checklist and challenges in transitioning to the role. Monthly forums were developed to provide opportunities for specific education and training. Some of the forum topics included data collection, change theory, and peer review. These processes have now become standard practice for our team as we continue to grow and develop.

Findings/Outcomes: Our group has risen above these challenges and is now a highly-functioning team. The team's contributions have far reaching implications for our organization. Improved patient outcomes and increased professional development of direct care nurses are just a few of the examples of the group's efforts. The team has grown from a group of 2 CNSs to a team of 9 population-based CNSs and 3 additional members functioning in the nurse Clinician Role as they continue to complete their CNS education.

Conclusions/Interpretations/Implications: The transition to the CNS model provided unique challenges to our group and organization. By using a multifaceted approach our organization has come to value the CNS role and has allowed new team members to feel supported into successful transition in their CNS practice.

Translating Evidence Into Practice: Piloting a Zero Fluid Displacement Needleless Connector for Central Vascular Access Devices

Olsen MM, Kellogg A, Swisher M, Johns Hopkins Hospital, Baltimore, Maryland

Significance: In 1992, the Federal Drug Administration (FDA) released a safety alert supporting the use of IV needleless connector (IVNC) access systems, and many FDA-approved needleless connectors have since been introduced. In 2011, a team of Advanced Practice Nurses at the Johns Hopkins Hospital Sidney Kimmel Comprehensive Cancer Center conducted an evidence-based practice (EBP) project using the Johns Hopkins Nursing EBP Model to identify the best needleless connector system, with specific interest in current FDA approved IVNCs' incidence of catheter-related bloodstream infections (CR-BSIs), design characteristics, and management protocols. The EBP team concluded that zero fluid displacement pressure devices have the lowest infection and contamination rates, and do not require specific flushing sequencing when used to ensure proper device function.

Design (Background/Rationale): Based on results of this EBP, the connector chosen was an FDA-approved product which met EBP specifications and had the lowest contamination rate based on published research. Through collaboration with the product company, a successful feasibility pilot study of the zero fluid displacement connector was conducted in an oncology outpatient setting. A larger pilot with oncology inpatients and outpatients is on-going.

Description of Methods: Central line-associated bloodstream infection rates, occlusion rates, nursing workload, nursing satisfaction prepilot and postpilot, and patient satisfaction postpilot will be analyzed using statistical software SPSS V.20.

Findings/Outcomes: Data analyzed to date demonstrated lower complication rates with the selected needleless connector. Central line-associated bloodstream infection rates, occlusion rates, nursing workload, and nurse and patient satisfaction will be presented and discussed in this presentation.

Conclusions/Interpretations: Final conclusions and interpretations of this pilot study will be presented at NACNS conference.

Implications: Clinical nurse specialists play critical roles in EBP, including conducting EBP projects and translating evidence into practice. Through product review, collaboration with leadership, education of Hospital staff, and evaluation of pilot projects to ensure the best products were selected based on evidence-based practice, the clinical nurse specialists led the initiative to find, procure, and justify the use of the best product for safe and effective patient outcomes. The connector chosen was selected based on published evidence, and the pilot study results will guide Hospital-wide purchasing, and policies and procedures regarding the selection of needleless connector systems across the entire Johns Hopkins Health System.

True Value of a Clinical Nurse Specialist: Reducing Contaminated Blood Cultures and Saving Healthcare Dollars

Hopkins K, Poudre Valley Health System, Fort Collins, Colorado

Purpose: A quality improvement project to find the best process for obtaining a blood culture specimen and diminish the contamination rate.

Significance: Using the correct method for obtaining a specimen reduces contaminated blood cultures and saves hundreds of thousands of dollars.

Design (Background/Rationale): In 2009, the rate of contaminated blood culture specimens at a community hospital was above 3% and an analysis indicated that the majority of the contaminated specimens were drawn by nonlaboratory personnel (nursing and physicians). A parallel question by staff nurses about the need to waste blood before obtaining a blood culture specimen was presented to the Evidence-Based Practice committee and a CNS agreed to lead a quality improvement project to find the best practice for obtaining a blood culture specimen and diminish the contamination rates.

Description of Methods: The CNS led a multidisciplinary group which included staff nurses from multiple patient care areas, microbiology technicians, and the laboratory educator. The group investigated current practice and determined that the laboratory staff had a rate of contaminated blood cultures that was well below the 3% benchmark and a probable reason for the low rate was determined to be a protocol and standardized method used to collect blood culture specimens. While the nursing and medical staff did not have a standardized method to follow, and the process was done differently by multiple practitioners. A literature review of information on blood culture specimens was assembled and used to gather data on best practice to follow when obtaining the specimen. The literature also defined the financial implications of a contaminated blood culture at $5000 to $8720/episode related to longer hospital stays of 4 days or more, unnecessary antibiotic therapy, removal of central venous catheters, stress for the patient, and additional laboratory testing.

Findings/Outcomes: A standard process for obtaining blood culture specimens was created from the literature findings and 3 separate nursing protocols were developed: obtaining a blood culture specimen from a central venous catheter; obtaining a blood culture specimen when an IV is started; and obtaining a blood culture specimen with a peripheral draw. All RNs were informed of the nursing protocols and were responsible to have their process observed by another RN before drawing a specimen independently.

Conclusions/Interpretations: Numbers of contaminated blood cultures were reduced from 3.5% to 1.3% in 1 month, with a savings of $105 000 to $183 120. The change in process has been sustained for 2 years with a contamination rate ranging from 0.9% to 2.7% and approximate savings of $1 080 000 in 2011.

Implications for Practice: A CNS led an interdisciplinary team to investigate best practice to follow when obtaining a blood culture specimen, which resulted in a standardized process for nursing staff, and reduction of contaminated blood cultures and substantial healthcare savings.

Two Studies: Perception and Occurrence of Bullying by Nursing Staff and Managers

Schaefer F, Lindy C, St Luke's Episcopal Hospital, Houston, Texas

Significance: A 2010 follow-up study by the Workplace Bullying Institute and Zogby International reported that 35% of all American workers were bullied at work. This represents 53.5 million American adults each year. Fifteen percent of the workforce has witnessed bullying at work1. Simons (2006) reported that 56% newly licensed and experienced nurses experienced bullying2. Findings from a prevalence study regarding negative workplace behaviors (NWB) led to a follow-up qualitative study exploring the perceptions of nurse managers on NWB.

Background: Negative workplace behavior has been researched under various descriptors: bullying 2, emotional abuse 3, horizontal violence 1, 4 lateral violence, 5 mobbing 3, and verbal abuse 5. Bullying is defined as unwelcome, repeated, hostile, aggressive behaviors (physical or nonphysical) of 1 colleague toward another. It includes humiliation, intimidation, and interference with job performance 3. Bullying affects the way nurses feel about their jobs, the ability to perform, and whether they stay at a facility. Some nurses indicated that the bullying incident was distressing enough to consider leaving the nursing profession 2. Staff do not report bullying; nurse managers tolerate the behavior. Some organizations foster the behavior through inaction 5. Despite the presence of literature about bullying pertaining to US nursing staff, none included the unlicensed assistive personnel (UAP). Also absent from the literature were studies investigating the nurse manager's perceptions.

Methods: Two separate studies were conducted to address the void in the literature pertaining to NWB. A mixed methods study determined the prevalence of negative workplace behaviors experienced by experienced RNs, newly licensed RNs and UAPs. Two hundred forty-five staff members responded to the Negative Acts Questionnaire Revised (NAQ-R), 23 of whom agreed to be interviewed. The qualitative arm consisted of a semi-structured interview with investigator-generated and demographic questions. The quantitative arm utilized descriptive statistics. A second qualitative study explored negative workplace behaviors or bullying with 20 nurse mangers. Researchers used a semi-structured interview guide with investigator-developed and demographic questions. Descriptive statistics were utilized to analyze the sample. Data were analyzed using the Colaizzi (1978) phenomenological method.

Findings: The majority of respondents in the mixed methods study experienced some form of negative behavior within the past 6 months. Effects of negative behavior on the person, teamwork and turnover were found to be congruent with previous literature. Open-ended questions enabled participants to share experiences when confronted with bullying behaviors. Six common themes emerged in each study from the data provided. Nurse managers reported observing bullying behaviors as staff nurses, but few reported observing NWB in their manager role.

Conclusions: Newly licensed nurses experienced less negative behavior than experienced RNs and UAPs. Nurse managers felt supported by the organization when handling bullying situations.

Implications: Findings from these 2 studies provide insight to organizations in identifying interventions that meet the needs of the nursing staff and nurse managers in handling negative situations. It may also enable organizations to set expectations for staff behavior and consequences for negative behaviors.

The Use of Concurrent Chart Review and Its Impact on Surgical Care Improvement Project Core Measures on Inpatient Medical/Surgical Wards

Lazarus AM, Pfennig P, US Air Force, San Antonio, Texas

Purpose: Using Thorndike's Law of Effect, we propose the use of concurrent chart review and appropriate recognition of desired behavior will result in increased compliance of SCIP measures.

Significance: Surgical site infections are the most common cause of nosocomial infections and are responsible for approximately 500 000 infections, 4 million excess hospital days, and $2 billion in increased healthcare costs annually. To reduce surgical infections, the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention developed the Surgical Care Improvement Project (SCIP) in 2006.

Design: During the period from April 2010-March 2011, BAMC achieved a 95% success on SCIP-1, 100% success rate on SCIP-2 and 86% success rate on SCIP-3 for total hip arthroplasty. During that same time period, BAMC achieved a success rate of 99% for SCIP-1, 100% for SCIP-2 and 89% for SCIP-3 for total knee arthroplasty. The top 10% of the hospitals nationwide and statewide achieved 100% on all 3 measures. In August 2011, a clinical nurse specialist (CNS) initiated concurrent chart audits. Problems identified included lack of documentation, lack or orders, or incorrect timing in the medication administration record (MAR). Failure to cohort patients in the facility resulted in an unfamiliar process those unfamiliar with SCIP measures.

Description of Methods: In an effort to increase SCIP-3 compliance rates for total hip and knee surgeries, a CNS performed concurrent chart reviews on patients receiving total joint replacements and provided immediate corrective action and education to the ward nurses. In instances where incorrect timing could lead to missed doses and the potential for incomplete antibiotic regimen, the ward nurses were educated individually to help them understand the importance of antibiotic timing. Nurses contacted the providers if an order for postoperative antibiotics was not written.

Findings/Outcomes: During August 1-December 1, 22 total hip replacements were completed. SCIP-3 compliance for this time period for total hip replacements was 100 percent. During that same time period, 41 total knee replacements were completed; SCIP-3 core measure compliance was 93 percent. Analysis of sustainment beyond December 2011 is presently being conducted.

Conclusions/Interpretations: Concurrent review of medication administration for total joint patients by the CNS is crucial PACU to the first 24 hours on the ward. Retrospective analysis of reasons of failure are outdated, useless, and do not benefit the patient or institution. Only real-time tracking, correction, and education will correct discrepancies and serve as immediate feedback to the staff involved.

Implications: The clinical nurse specialist, with advanced education in pharmacology, systems theory, and organizational workflow, is integral to successful compliance with SCIP core measures. The CNS is an essential member of the healthcare team who is able to continually assess, identify, and correct gaps in nursing practice, knowledge, and compliance. Evaluation of outcomes has led to the following CNS recommendations: stressing continued physician compliance with postoperative order sets; ongoing PACU engagement to build awareness of SCIP initiatives for total joint surgeries, and providing feedback to individual staff nurses.

The Use of Simulated Clinical Experiences in an Accelerated Graduate Nursing Program

Grimes CE, Becker H, Hudson S, Zuniga J, Lin L-C, Patton S, Shammas A, The University of Texas at Austin School of Nursing

Purpose: To examine effects of simulation experiences on semester learning in second degree graduate students.

Significance: Because of realistic responses, sophisticated, interactive mannequins are used to create educational opportunities for nursing students. For clinical nurse specialist education, high-fidelity mannequins can offer nursing students practice opportunities at relatively sophisticated levels in safe environments. Research is needed so that curriculum change involving simulation can be grounded in evidence. Without evidence that human-patient simulation is effective, schools of nursing may be wasting effort, time, and money. An interesting finding from a study completed at our school of nursing in summer 2012 was that concurrent observation of bedside decision-making using the Lasater Clinical Judgment Rubric (2005) will perhaps require more sophisticated methods of observer selection and training. The establishment of sound interrater reliability within simulation centers will ensure that students' application of knowledge in simulated settings can be accurately measured.

Design: Data were collected from 55 students: 30 engaged in simulation in place of 1 day of clinical experience. Analysis of variance was used for precomparison and postcomparison of knowledge of groups. Students were to enter into 2 scenarios in teams of 3 and were to assess, plan, intervene, communicate effectively, and evaluate following a series of nursing actions.

Methods: As 1 of 5 measures used in the study, the Lasater Clinical Judgment Rubric (LCJR) was used to examine the effects of simulation on student aptitude, experience, confidence, and skill in clinical judgment. In our study, the instrument was used by 3 raters who observed either from a control booth with one-way glass or from film. With students' previous levels of education, motivation to succeed, and the requirement that they continue on into master's study culminating in CNS, NP, or other advanced degrees in a short period of time, our school needed to measure the worth of our simulation activities in preparing the students. The LCJR measured such elements of performance as prompt recognition of deviations from expected patient patterns, effective interpretation, clear communication and response, well-planned intervention, and effective evaluation of efforts within the scenario.

Findings: Results from other measures within the study, such as student self-ratings upon completion, were largely positive. These measures related to confidence, communication, knowledge, and teamwork. Surprisingly, results from interrater reliability analysis among the observers yielded negative values.

Conclusions: Other studies have reported positive self-ratings by students following simulation. This study also yielded primarily positive reactions on the part of students. However, when investigators discovered disparity in observer scores, interrater reliability studies' negative values indicated widely differing views by each of the 3 observers. Looking more deeply, it became evident that differing backgrounds and experiences of these nursing graduate students, combined with lack of training and testing accounted for scoring disparities.

Implications: There is need for caution in measuring results when teams of observers are employed. Planning for observer training and testing is needed by schools that will adopt simulation as a strategy.

Using a Diffusion Model to Reduce Urinary Catheter Utilization and Associated Urinary Tract Infections (CA-UTI) Across a Healthcare Organization: 1 Location's Perspective

Negley K, Maxson P, Wangen T, Mayo Clinic, Rochester, Minnesota

Purpose: The purpose of this presentation is to discuss the clinical nurse specialist (CNS) role in the diffusion of an organization-wide effort to decrease catheter-associated urinary tract infection (CA-UTI) rates by decreasing urinary catheter utilization by 20%. A Diffusion Model, based on the Institute for Healthcare Improvement's Framework for Spread, was utilized.

Significance: Urinary tract infections are the most common type of healthcare-associated infections (HAI), accounting for more than 30% of infections reported by acute care hospitals. Implementation of guidelines to reduce urethral catheterization is critical to meeting the national strategy goal of reducing HAIs. As a change agent, the CNS provides essential skills to support diffusion of best practice into the clinical environment.

Design: Guidelines were developed for the prevention of hospital-acquired CA-UTI using evidence-based practice. Three best practice elements were implemented at all locations: ensuring indwelling catheters are only used when clinically indicated, daily assessment of continuing need, and prompt removal when a urinary catheter is no longer indicated.

Methods: The Diffusion Model was utilized by a multidisciplinary team to standardize practices and improve quality and safety of patients. Clinical nurse specialists were vital in implementation of Diffusion Actions in 3 spheres of influence. Work in the patient sphere included assisting with the development of an educational brochure given to patients when a catheter is placed. The brochure highlights the importance of prompt removal. The nurse sphere was impacted in the areas of documentation and education. Documentation changes within the electronic environment now require nurses to complete a daily assessment of continued need on patients who have a urinary catheter. Education of 6200 nursing staff was accomplished via an online educational module and tracked through an educational system resulting in a 93% completion rate. Additional articles were published in the nursing and prescriber newsletters. To ensure prompt removal when a urinary catheter is no longer indicated, the CNS worked within the systems sphere partnering with information technology to develop prescriber alerts triggered by nursing documentation.

Outcomes: The guidelines were fully implemented July 2012 at the largest medical center. As a result of this effort, an indication for catheter placement is designated and a daily assessment of continued need is completed greater than 90% of the time achieving the organizational goal. There was a 23% reduction in urinary catheter utilization rates. Catheter-associated urinary tract infection was reduced by 11% in the ICU setting and 7% in general care.

Conclusions: The CNS characteristics of leadership and collaboration played a critical role in the value creation, diffusion actions, and operational implementation phases of the CA-UTI initiative. Pivotal communication by the CNSs with the various disciplines involved with the project created collaborative systems interventions which changed current nursing and provider practices to align with evidence-based guidelines.

Implications: The organizational diffusion of the CA-UTI prevention guidelines was effective because of the Diffusion Model. This model provides a framework for large organizations to develop and implement standardized evidence-based practice guidelines.

Using an Inquiry-Based Approach to Understand Interprofessional Collaboration

Malagon-Maldonado G, Kindred Healthcare, Whittier, California

Significance: Effective interprofessional collaboration is needed in long-term acute care hospitals (LTACHs) where the majority of patients have multiple comorbidities, are seen by various clinicians, and have longer lengths of stay. Traditionally, interprofessional collaboration has been studied in the literature by using diverse frameworks and methodologies which do not facilitate knowledge translation and the building of collaborative practice and evidence. It is essential that interprofessional collaboration be well understood in a context by which healthcare providers know they are collaborating to successfully deliver quality patient care. This is especially true for nurses who are at the center of this care coordination necessary for safe and effective care.

Purpose: The first purpose of this study was to assess the intensity of interprofessional collaboration in a LTACH using the Interprofessional Collaboration Questionnaire and identify differences among RNs and other healthcare providers. The second purpose was to understand healthcare providers' experiences with effective interprofessional collaboration by exploring how it is lived in practice through individual and small group interviews. The third purpose was to identify the gaps in the literature on interprofessional collaboration practices and the research findings.

Design: This study used an inquiry-based approach to facilitate knowledge translation to understand interprofessional collaboration. The approach used epistemological sources of knowledge (assessing the intensity of collaboration), ontological sources of knowledge (understanding how providers are in collaboration), and ethical sources of knowledge, identifying how they are delicately intertwined in every nursing action.

Methods: This mixed-methods research study included questionnaires completed by healthcare professionals providing quantitative information about beliefs related to interprofessional collaboration. Using interpretive phenomenology as the qualitative methods design, interviews further explored healthcare providers' experiences with interprofessional collaboration. The current knowledge about collaboration in the LTACH was compared with the existing literature on interprofessional collaboration.

Findings: From the questionnaire, higher levels of interprofessional collaboration were reported among RNs than other providers (P = .012), particularly between RNs and respiratory therapists (P = .000). The narratives provided further insight where nurses emphasized the importance of clinical knowledge that encompasses knowing the patient, one's own role, and the role of others in collaboration. Nonetheless, doing what is best for patients and achieving optimal outcomes resonated in the narratives of all healthcare providers where ethical knowledge was seen as the unifying theme in effective interprofessional collaboration. What is experienced by professionals involved in collaborative practice in this study and what is conceptualized to be the influences of interprofessional collaboration in the literature vary.

Conclusions and Implications: Using an inquiry-based approach, nurses demonstrated the ability to collaborate effectively using clinical and ethical expertise in practice. They are positioned to lead the role in effective care coordination among providers using different patterns of knowing in which clinicians can develop a better grasp of collaboration caring for medically complex patients.

Validation of Clinical Nurse Specialist Core Practice Outcomes

Fulton JS, Indiana University, Indianapolis; Mayo A, Urden L, University of San Diego, California; Walker J, Purdue Calumet, Hammond, Indiana

Purpose: This descriptive exploratory study aimed to validate core clinical nurse specialist (CNS) outcomes in a population of practicing CNSs and to describe the frequency of (1) accountability, (2) importance, and (3) monitoring of each outcome.

Significance: Clinical nurse specialists must document outcomes to communicate contributions to patient outcomes. NACNS identified 42 CNS core practice outcomes within the spheres of influence (patient, nurse, and organization) framework; however, evidence supporting these outcomes is anecdotal.

Design/Methods: A Web-based survey was used (REDCap Survey) to collect data. Participants were recruited from NACNS membership and an international CNS listserv. An investigator-designed self-report questionnaire used the Spheres of Influence framework for organizing the core outcomes.

Findings: Four hundred twenty-seven surveys returned; 347 (81%) were included in analysis.

Participants: Sixty-two percent held master's degree (highest earned); average of 10 years experience in the CNS role (SD, 8.8); 37% held advanced specialty certification; 13% had prescriptive authority. Most important outcomes: evidence-based practice (EBP) (92%, 93%, and 91% in patient, nurse and organizational spheres respectively). Outcomes most frequently held accountable for: collaboration (92%, patient sphere, EBP (87% and 86%. nurse and organization spheres respectively). Most monitored outcomes by CNSs: nursing interventions (68%, patient sphere), EBP (66% and 51%, nurse and organizational spheres respectively). Lowest ranked outcomes were related to diagnosing and cost/revenue. When job descriptions included CNS outcomes more CNSs reported using the outcomes in practice. Both accountability and importance predicted the monitoring of those outcomes (P < .0001).

Conclusions: This study provides evidence of concordance between NACNS identified outcomes and practicing CNSs. Greater emphasis is needed on monitoring outcomes. Rankings demonstrate CNS orientation to a nursing model (versus medical model) and a leadership model (versus management) for directing patient, nursing, and organizational initiatives.

Implications for Practice: EBP in all 3 spheres is an important outcome for CNSs in terms of direct patient care, leading nurses, and organizational programming. Increased efforts are needed to develop methods for monitoring and reporting outcomes of CNS practice.

Who Turned Out The Lights?: Implementing a Midday "Quiet Time" on an Acute Care Medicine/Pulmonary Unit

Havey R, Monticciolo M, University of Michigan Health System, Ann Arbor

Purpose/Objective: To determine if the implementation of a midday quiet time can promote rest and relaxation and improve sleep in patients on an acute care medicine/pulmonary unit.

Significance: Noise levels greater than 50 decibels can decrease healing, impair recovery, and increase length of stay (Boehm and Morast, 2009). The EPA recommends noise levels between 35 and 45 Db within the hospital environment.

Background/Rationale: Noise had previously been identified as a patient dissatisfier within our institution. Identifying interventions to reduce noise had become a priority. Implementation of a quiet time is an example of an intervention that can be used to reduce noise in a hospital environment.

Description of Methods: Surveys were conducted of patients before and after the implementation of quiet time. Patient surveys were provided at discharge and focused on sleep patterns while in the hospital, fatigue, and factors that either prevented or promoted rest. Nursing staff members were also surveyed preimplementation to provide insight into the workload and perception of noise on the unit and to elicit feedback from staff to determine when quiet time should take place. Quiet time was implemented from 1300-1500 daily on the unit. Education was provided to staff regarding the importance of promoting rest and reducing noise. At 1245, an overhead announcement is made reminding patients and staff that quiet time will be starting. At 1300, the lights in the main corridors are dimmed and patient doors are closed as appropriate. Signs are posted on the doors to the unit to remind staff and visitors that quiet time is in effect.

Findings/Outcomes: Fifty-nine percent of patients surveyed felt tired or fatigued during the day preimplementation versus 63% postimplementation. Fifty percent of patients felt rested during the day preimplementation versus 57% post. The percentages of patients receiving 2-4 and 4-6 hours of uninterrupted sleep increased from 34% to 43% and 31% to 35%, respectively. Factors that interrupted sleep the most included vital signs and IV pumps both preintervention and postintervention. The use of sleep masks increased 10% and earplugs increased 4%. The use of headphones was unchanged at 11%. Notably, the use of medications to facilitate sleep decreased from 77% to 63%. Seventy-one percent of patients felt that quiet time helped them to rest or relax during the day.

Conclusions/Interpretations: When implementing an intervention that is largely dependent upon behavioral changes, it is imperative to continuously monitor for successes and set backs and provide follow-up. The implementation of quiet time has resulted in more patients using nonpharmacological methods to facilitate sleep and reduced the use of medications. Overall, patients are receiving more sleep at night.

Implications: The implementation of quiet time on an acute care medicine/pulmonary unit can promote rest and relaxation, encourage the use of nonpharmacological alternatives to facilitate sleep, and reduce the use of sleep medications.

You Stuck With No Luck? Emergency Nurses Use Ultrasound to Access Peripheral IVs

Burnie J, Seymour A, Bethesda North Hospital, Cincinnati, Ohio

Purpose/Objectives: Describe the benefits of implementing an ultrasound guided peripheral IV program in emergency departments (ED). Discuss the role of the clinical nurse specialist in integrating an ultrasound guided peripheral IV program in the ED.

Significance: Nearly every patient that presents to the ED receives intravenous access (IV) and blood sampling. Multiple reasons may cause a patient to have limited vascular access. The use of ultrasound to enhance visualization and cannulation of deep veins improves success rates of IV access, improves time to treatment and enhances patient satisfaction.

Design: The ED clinical nurse specialist (CNS) and an innovative ED staff nurse searched the literature to determine best evidence to support the introduction of ultrasound guided IV access by ED staff nurses. The ED CNS collaborated with the critical care CNS with responsibilities for peripherally inserted central catheters (PICC) to ensure that appropriate equipment and education was developed.

Description of Methods: A literature search was conducted using OVID and emergency nursing publications. Limited research was available. Evidence revealed similarities in vein access, patient satisfaction, decreased complications and high-risk procedures and improved cost and time saving in the ED. The CNS wrote a grant to the hospital foundation, which allowed for the purchase of a vascular probe specific for deep vein visualization. An educational program was developed and a core group of experienced ED nurses were chosen to pilot the program. A guideline and competency tool was developed and several ED physician colleagues collaborated with the nurses to ensure competence with the procedure.

Findings/Outcomes: A tracking tool was developed to capture both successful and unsuccessful attempts. In 3 months, 8 of the 12 core nurses achieved competency. These nurses are averaging 1 to 2 sticks per day. Previous alternative methods to achieve IV access cost the organization $750.00 to $1750.00 per patient with femoral vein access by a physician or central venous line placement. The savings to the organization is estimated to be $270 000.00 to $630 000.00 annually. Emergency department staff nurses have placed over 150 IV's using ultrasound guided assistance since February 2012. Patients report less pain with ultrasound-guided technique.

Conclusions/Interpretation: It is possible for the CNS in the ED to mentor staff nurses to search the literature and adapt findings to develop a program that will impact patient outcomes.

Implications for Practice: Additional training sessions are scheduled due to requests of other nurses to become involved in the team. There is an increased demand on the ultrasound machine, so alternatives are being investigated. The PICC team has seen a decrease in requests for assistance in placing IV's in the ED.