AACN Advanced Critical Care Volume 26, Number 1, pp. 35-42 © 2015 AACN
Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery Lisa M. Soltis, RN-BC, MSN, APRN, PCCN, CCRN-CSC, CCNS
ABSTRACT Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an
interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period. Keywords: cardiac surgery, clinical nurse specialist, extubation, nursing, outcomes, performance, performance improvement
H
ealth care reform continues to focus on improving patient outcomes while reducing costs. As clinical nurse specialists (CNSs), this focus on improved outcomes and reduced costs represents an opportunity to demonstrate our ability to affect both patient outcomes and fiscal responsibility. Within the CNS role, not only do we strive to improve patient outcomes, but we also evaluate processes and procedures to ensure best practice standards and patient safety, and we work to support clinical staff nurses to ensure they have the resources necessary to achieve quality outcomes. This article illustrates the impact a CNS can have on evaluating clinical interventions and care, improving system processes, and leading multidisciplinary teams to improve patient care outcomes.
gram or clinical area that coincides with his or her certification and expertise. The skills and knowledge required for this role include clinical expertise, evidence-based practice, collaboration, education, mentoring, and leadership to function as a change agent. These specialized skills and knowledge are used within 3 major areas of focus: nurses and nursing practice, patients and families, and organizational needs.1 The CNS is an integral part of the organization and brings a unique clinical focus to his or her practice. Clinical nurse specialists are particularly skilled at using evidence to drive performance improvement (PI) initiatives to improve patient outcomes and safety. Because CNSs may have many different
Background
Lisa M. Soltis is Clinical Nurse Specialist, Cardiothoracic Surgery, Sentara Heart Hospital, 600 Gresham Dr, Norfolk, VA 23457 ([email protected]).
Clinical Nurse Specialists
The author declares no conflicts of interest.
The CNS is an advanced practice nurse who serves as a clinical leader for a particular pro-
DOI: 10.1097/NCI.0000000000000070
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responsibilities, their role can be confused with other roles within an organization. The CNS should understand the role and be able to articulate his or her responsibilities and integrate activities with other disciplines in the organization.2
heart surgery. The national average for patient extubation within 6 hours of surgery was 39.5%. Our data showed that the average number of patients who were extubated within that time frame was only 14.4% through April 2012. Another opportunity for improving quality of care was related to the number of patients who required transfer back to the cardiothoracic intensive care unit (CTICU) from the progressive care unit (PCU). Historically, approximately 5% of our patients after cardiac surgery required readmission to the CTICU. In April 2012, the data showed that the readmission rate had increased to more than 10% of all cardiac surgical patients. According to the STS database, the national benchmark for this standard was approximately 10% of all patients for this particular population. In addition, of those patients who required readmission to the CTICU, 60% had pulmonary complications, such as hypoxia and pulmonary edema. The ideal standard of care is to extubate patients within 6 hours after open heart surgery.5 Nurses are responsible for all aspects of patient care, including collaborating with respiratory care practitioners (RCPs) to facilitate weaning ventilator support.2,5 Programs that use fast track nursing extubation protocols have demonstrated no increase in morbidity or mortality rates and actually may improve patient outcomes.3–9
Reduction of Postoperative Complications
The clinical and organizational need to decrease intubation times and decrease respiratory complications in patients who have had open heart surgery is well documented in the literature.3–12 Early extubation after open heart surgery is a critical component of fast track protocols and can help reduce the development of pulmonary complications in the postoperative period while decreasing overall hospital length of stay (LOS). Cheng6,7 showed a 25% reduction in patient care costs as a result of early extubation protocols that led to a significant decrease in intensive care unit (ICU) LOS and a decrease in pulmonary complications. In addition, when patients experience complications, such as arrhythmias, hypotension, or hypoxia, in the postoperative period, they may require readmission to the ICU to manage their symptoms. A readmission can interrupt continuity of care for the patient as well as lead to increased hospital costs associated with the need for a higher level of care and monitoring.2,12 As part of a cardiothoracic surgery program, clinicians must submit specific data points for each patient to The Society of Thoracic Surgeons (STS). The mission of the STS is to enhance the ability of cardiothoracic surgeons to provide the highest-quality patient care through education, research, and advocacy. The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons.13 This professional organization reports data measures quarterly for each hospital in addition to comparative data to similar facilities and national benchmarks. While evaluating patient outcomes and morbidity data from the STS database reports for our institution, we noted an increase in LOS for our patients in comparison with similar facilities, as well as an increase in pulmonary complications in the postoperative period. Opportunities for improvement were related to prolonged intubation times in the immediate postoperative period in patients who had open
PI Plan Team Members and Setting
On the basis of best practice recommendations from the STS and review of our postoperative cardiac surgery data, our CTICU interdisciplinary team initiated a PI project to improve early extubation rates and to decrease the number of readmissions to the CTICU. This project was conducted in a 12-bed CTICU and a 40-bed PCU in a large medical center in the southeastern United States. This health system has more than 900 beds and performs more than 600 cardiac surgical procedures annually. The PI team was led by the CNS and the nurse manager for the CTICU. Initial team members for the CTICU project included nurses from the CTICU, the nurse manager from the cardiothoracic surgery unit, supervisor/educators, RCPs, and our STS data analyst. An analysis was completed to ascertain our strengths, weaknesses, 36
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opportunities for improvement, and threats/ barriers (SWOT analysis). This group was actively engaged as a team to improve care for our patients and focused on creating individualized plans of care based on patient needs, while maintaining a focus on patient safety. The goal was to increase the number of CTICU patients who were extubated in less than 6 hours to 40% by July 2013.
dure as well as the length of time on cardiopulmonary bypass, and availability of adequate personnel at shift change to facilitate weaning progression and assist with extubation. Actions were taken on the basis of analysis of the extubation evaluation forms. Inservices were conducted by the CNS and the data analyst with the anesthesiology team to ensure that patients would be adequately reversed from anesthetic agents at the time of transfer to the CTICU. The importance of early extubation was emphasized with the entire care team, including nursing and respiratory care services through inservices by the CNS. Many surgical patients were ready for extubation during shift changes, when RCPs were unavailable to assist because of handoff reporting. Respiratory care services made changes to their staffing patterns that allowed a lead therapist to be available to assist with extubation during shift changes. Having the lead therapist available for the nurses allowed continued progression of weaning efforts, regardless of time of day. The CNS and the nurse manager collected data weekly to provide team members with real-time data, which allowed timely evaluation of the weaning process. The CNS sent weekly updates to the entire nursing, respiratory, and leadership teams to communicate progress and to congratulate members of the team who achieved successful outcomes with their patients. This process helped keep the team engaged and gave time-sensitive feedback to nurses and RCPs.
Early Extubation
Between April 2012 and June 2012, the Cardiothoracic Surgery PI Project Team, led by the CNS, met biweekly to determine what interventions would improve our extubation rates. The clinical nurses and RCPs looked at our existing extubation protocol and discussed possible changes with the surgeons and intensivists to determine whether any modifications could be made. A new respiratory extubation protocol was developed to improve communication and weaning progression for clinical nurses and RCPs to implement. We researched potential risk factors for prolonged intubation and pulmonary complications to facilitate identification of high-risk patients.10,11 Clinical staff nurses also facilitated the process to have the new protocol presented at various internal meetings required for approval, which allowed the protocol to be embedded in the existing postoperative order set. Nurses noted that in certain cases, stabilizing oxygenation when the patient first came out of the operating room was a challenge. When they discussed these findings with the anesthesia team, the nurses discovered that different ventilator settings were used during surgery compared with the settings that were being used in the critical care unit. The CNS, nurse manager, surgeons, intensivists, and anesthesiologists discussed this discrepancy and decided to standardize the ventilator settings in both care environments to improve oxygenation and provide a consistent plan of therapy. The CNS and nurse manager created an extubation evaluation form for use by the clinical nurses when a patient could not be extubated within 6 hours. The CNS and the PI team evaluated the forms and identified possible barriers when targets for extubation were not achieved. Factors that contributed to longer intubation times included patients with a significant history of pulmonary disease, reversal of anesthetic agents upon transfer to the CTICU, the length of the surgical proce-
Readmission to the CTICU
Simultaneously, in April 2012, a subcommittee of the Cardiothoracic Surgery PI Project Team was formed to focus on post–cardiac surgery patient care management from the intermediate care perspective. This team also included the CNS, the CTICU manager, the PCU manager, the supervisor/educators, advanced practice nurses, physician assistants, respiratory care services, and clinical nursing staff from both the CTICU and the PCU. We had previously discovered in our data analysis that many of our patients experienced pulmonary complications in the postoperative period. Feedback from the clinical nurses indicated that many patients did not want to participate in their breathing exercises, some were reluctant to ambulate, and variation existed in the respiratory care treatments. The goal for this 37
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team was to decrease the number of patients who required readmission from the PCU back to the CTICU from 10% to 5% by July 2013. The team developed an evaluation tool to review each incidence when a patient required readmission to the CTICU. We evaluated the overall hospital course, preoperative comorbidities, surgical complications, CTICU course of care, date of transfer to the PCU, and any potential contributing factors that led to the development of complications. These data were reviewed with clinical nurses in both the CTICU and the PCU to help identify trends that may have contributed to the need for a higher level of care. In addition, respiratory care services developed an assessment tool that was used by the RCP that quantified the patient’s respiratory symptoms and history to determine the frequency of the patient’s treatments, such as nebulizer therapy and the use of a positive expiratory pressure mask with vibrations to help facilitate removal of pulmonary secretions. The use of the positive expiratory pressure mask has been found to significantly improve clearance of pulmonary secretions and is better tolerated by patients compared to traditional chest physiotherapy.14 Daily pulmonary rounding huddles were completed on all cardiac surgery patients in the PCU with the RCPs, the CTICU charge nurse, the PCU charge nurse or rounding nurse, the CNS, and the advanced care practitioners (acute care nurse practitioner or physician’s assistant). During these huddles, updates could be made to the patient’s treatment plan and communicated to the care team. During the daily respiratory huddles and discussions with respiratory care services, we discovered that orders for treatments every 6 hours were administered differently than orders for treatments 4 times daily, which would be administered in the morning, at lunch, at dinner, and before bedtime. Consequently, communication was significantly improved between disciplines through these daily rounds. The CNS, clinical staff nurses, and team members developed tools and algorithms to improve patient management when potential problems were identified after transfer to the PCU. These algorithms or flow diagrams for the PCU included critical thinking maps for hypotension, bradycardia, tachycardia, and hypoxia, which were the most common clinical findings observed in the postoperative
period. These tools were developed by the CNS, advanced practice care practitioners including acute care nurse practitioners and the surgical physician assistants, and the clinical staff nurses, and were created from existing treatment protocols and our standard postoperative orders. For example, the flow diagram for atrial arrhythmias illustrated a stepwise process for the nurse to follow in managing the patient, starting with the assessment process. These tools also improved communication among the care providers, so when the nurse called to notify the physician or midlevel provider, specific assessment findings were used during the communication process (see Figure 1). These flow diagrams also were used to educate clinical nurses on the PCU to facilitate critical thinking before calling the physician and requesting readmission to the CTICU. These algorithms were emphasized during inservices with the nurses to help improve critical thinking skills. The nurses became so familiar with the algorithms, they no longer needed to refer to the protocols but rather the concepts were incorporated into their plan of care and daily workflows, which led to a dramatic improvement in their critical thinking skills and improved focus on prevention of complications. The nurses also emphasized patient and family education on the importance of breathing exercises and ambulation to prevent possible complications. The PI team also decided to implement a rounding nurse role specific to our patient population to follow up on patients who were at high risk of return to the CTICU based on specific clinical criteria (Table 1). The rounding nurse or consulting nurse was assigned daily from the CTICU and was responsible for rounding on high-risk patients who had been transferred to the PCU the previous day, or who required continued follow-up. The goal of the CTICU consulting nurse would be to see the patient every 4 hours for the first 24 hours and continue to see the patient for longer than 24 hours if indicated. Indications for continued rounding included anytime the PCU requested assistance with changes in a patient’s condition or any patient who was not progressing according to accepted unit standards. This process was designed to ensure progression of care and additional ongoing assessment of the patient to ensure that no significant changes occurred in the patient’s condition 38
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Atrial Arrhythmias with Rapid Ventricular Response
CNS ROLE IN CA RD IAC SURGE RY IM P ROVE M E NT S
New A-Fib or A-Flutter
Check BP
Prepare ordered antiarrhythmics. Order ECG. Central line access?
Unstable, HR > 120
Stable, HR > 120
SBP < 90
SBP > 90
7A-7P Notify NP/PA. Notify CTICU consulting RN for CT Surgery patients. Call ICU rounding RN for all other patients if needed. 7P-7A Call Cardiology NP/PA if consult in place. Call surgeon if no orders in place.
Update BP, symptoms (if present), medications.
7A-7P Notify NP/PA Notify CTICU consulting RN for CT Surgery patients. Call ICU rounding RN for all other patients if needed.
Do Not Give Cardizem! Get the Code Cart
7P-7A Call Cardiology NP/PA if consult in place Notify CTICU consulting RN for CT Surgery patients. Call ICU rounding RN for all other patients if needed. Notify surgeon if patient does not respond to interventions, if needed.
Update BP, symptoms (if present), medications. Obtain stat K, Mg.
Give medications as ordered. Check labs as ordered (K, Mg, H&H)
Midlevel to order stat K, Mg, H&H if needed.
If midlevel or surgeon orders and patient has central access (no lung, liver or thyroid Hx) notify pharmacy for amiodarone bolus & drip.
Let NP/PA know VS, symptoms, and if central access is present.
Figure 1. Algorithm for management of atrial arrhythmias. A-fib indicates atrial fibrillation; A-flutter, atrial flutter; BP, blood pressure; CT, cardiothoracic; CTICU, cardiothoracic intensive care unit; ECG, electrocardiogram; H&H hemoglobin and hematocrit; HR, heart rate; Hx, history; ICU, intensive care unit; K, potassium; Mg, magnesium; NP, nurse practitioner; PA, physician assistant; SBP, systolic blood pressure; VS, vital signs. This figure is available in color in the article on the journal website, www.aacnadvancedcriticalcare.com, and the iPad.
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Extubaon in Less Than 6 hours
Table 1: High-Risk Criteria for Readmission to the ICU
Postintervention
Percentage of Extubations < 6 hours
80.00%
Prolonged Intubation time > 48 h History of COPD, impaired pulmonary function, poor CDB effort, incentive spirometer < 1000 mL Increased oxygenation needs, use of high flow oxygen Complicated postoperative course Chest radiograph with atelectasis
70% 70.00% 60.00%
63% Preintervention
48%
50.00%
28.60%
30.00% 20.00%
14.40%
10.00% 0.00% 2012 Q1
2012 Q3-Q4
2013 Q1
2013 Q2
2013 Q3
Percentage 14.40% 28.60%
48%
63%
70%
Decreased oxygen saturation levels < 92% Decreased ejection fraction < 25%
Goal was to increase # of extubaons to > 40%
40.00%
Date/Time Frame
Vasoactive medications within 4 h of transfer
Figure 2. Graph showing progress of increasing extubations in less than 6 hours. This figure is available in color in the article on the journal website, www.aacnadvanced criticalcare.com, and the iPad.
Significantly impaired mobility Impaired renal function with oliguria, elevated BUN/creatinine Altered level of consciousness, confusion Any clinical condition that would give the nurse cause for concern
decreased from 22.8 to 11.1 hours, and the reintubation rate remained consistent at 2.9%, below the national average of 3.7%. During the same time period, no failed extubations required emergent reintubation. Our partnership to improve patient management in the intermediate care environment resulted in reduced returns to the ICU to 2.6% (down from 7.4%) (see Figure 4). Returns related to pulmonary complications, such as pulmonary edema or hypoxia, decreased to 27% (from 60%). In addition, patients with any pulmonary complication in the postoperative period, regardless of the need for readmission to the ICU, also decreased to 11% (from 21.2%).
Abbreviations: BUN, blood urea nitrogen; CDB, cough/deep breathe; COPD, chronic obstructive pulmonary disease; ICU, intensive care unit.
after the patient left the CTICU. Early assessment and recognition of changes in the patient’s condition ensured earlier intervention to improve patient outcomes. The consulting nurse was already caring for patients in the CTICU; therefore, no additional cost to the unit was incurred in implementing this role. The CNS and the manager completed in-depth data collection for case reviews of each patient who was readmitted to the CTICU. These data were then shared at staff meetings for the benefit of all nurses and practitioners involved in patient care. Facilitation of discussion during the case reviews was led by the CNS and the nurse manager to ensure appropriate focus on teachable moments and learning opportunities. These discussions also generated ideas for future management of similar situations if they occurred again.
Secondary outcome observed but not part of original goals. Naonal average was 10%
Outcomes Our partnership to promote early extubation resulted in a significant increase in the number of patients extubated in less than 6 hours from a baseline of 14.4% to 48% (see Figure 2). A secondary outcome achieved with this project resulted in a decrease in prolonged intubations (> 24 hours) to 7% (down from 15.7%) (see Figure 3). Mean initial ventilation hours
Prolonged Intubations >24 hours
Prolonged Intubaons > 24 hours
18.00% 16.00%
Preintervention 15.70% Postintervention
14.00% 11.50%
12.00% 10.00%
8.80%
8%
8.00%
7% 5%
6.00% 4.00% 2.00% 0.00%
Q2 2012
Q3 2012
% >24 hrs 15.70% 11.50%
Q4 2012
Q1 2013
Q2 2013
Q3 2013
8.80%
8%
7%
5%
Date/Time Frame
Figure 3. Graph showing prolonged intubations. This figure is available in color in the article on the journal website, www.aacnadvanced criticalcare.com, and the iPad. 40
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passes the entire scope of the patient experience is critical to success. As CNSs, our role can facilitate that process through the various aspects of our training and education. As evidence-based practice experts, we must ensure that best practice standards are met through literature review and that clinical standards established by governing organizations are clearly understood and implemented. Clinical experts should communicate the standards set forth by the STS and ensure that all members of the PI team and clinical nurses are aware of the appropriate definitions and expectations of care. Everyone involved with this project was engaged and excited about improving our patient outcomes, so the need to change any unit-based cultural changes/beliefs was moot.
Readmissions to CTICU from PCU Preintervention
8.00%
7.40%
Percentage of Returns
7.00% 6% 6.00%
6%
Postintervention
5.40%
5.00% 4.20% 4.00% 3.00%
2.60% 1.80%
2.00% 1.00% 0.00%
Returns to ICU
2012 Q1
2012 Q2
2012 Q3
2012 Q4
2013 Q1
2013 Q2
2013 Q3
7.40%
6%
5.40%
6%
4.20%
2.60%
1.80%
Date/Time Frame
Figure 4. Graph showing readmissions to the ICU. CTICU indicates cardiothoracic intensive care unit; ICU, intensive care unit; PCU, progressive care unit. This figure is available in color in the article on the journal website, www.aacnadvancedcritical care.com, and the iPad.
Summary This PI project to decrease extubation times in patients who had cardiac surgery allowed us to successfully demonstrate that early extubation leads to improved patient outcomes, which in turn can lead to a decreased LOS and decreased hospital costs. Using an interdisciplinary approach, patient management and patient flow were maximized by achieving a decrease in returns to the CTICU as well. Keeping the team members aware of our progress helped maintain engagement and enthusiasm for changing and improving our practice. The CNS and the clinical nurses were continually providing feedback to each other and to leadership, which also helped keep the team motivated. Being able to articulate what we do as CNSs, and to tie those activities to patient outcomes, is vital to ensuring that the CNS role will continue to thrive.
The financial impacts of these improvements were astounding. We achieved a reduction in LOS by 2.2 days during this project. When averaged over the number of cardiac surgery cases completed, this change equated to an approximate reduction in cost of more than $2 million. This cost-reduction estimate did not include the decreased need for additional patient care resources, the reduction in expenses related to ventilatory care and support, or the reduction in nursing care hours. We achieved improved patient flow by allowing earlier transfers to the PCU, which increased the availability of ICU rooms to ensure that the operating room could transfer patients in a timely fashion. Qualitative studies have shown that common themes from the patient perspective during ventilatory weaning include physical discomfort, impaired communication capabilities, and fear/anxiety related to the weaning process.3,15 Therefore, earlier extubation also can result in improved psychological well-being for patients. We observed that patients’ families were very happy to see their loved ones progress so quickly and safely toward discharge home.
Acknowledgments I thank everyone involved with this project, especially Ellen Wheaton, RN, BSN, CCRN, nurse manager. Her undying commitment to patient safety and quality outcomes is unparalleled, and she has been an amazing mentor. Other members of the team included Thomas Del Corro, RN; Kelly Thompson-Brazill, RN, MSN, ACNP-BC, CCRN-CSC, FCCM; Melissa Chapin, RN, BSN, CCRN; Wanda Adams, RN, BSN, CCRN; Dana Earle, RN, BSN, CCRN; Sharon McDonald, RN, BSN, CCRN; Sarah Hale, RN, PCCN; Gina McConnell, RN, CCRN; Sandra Vanscoy, RN, BSN, NE-BC; Megan Swink, RN, PCCN; Patricia Jones, RN, PCCN; Wayne Warden, RCP; Paul Keene, RCP; Jen White, RCP; Jeffrey Lamphere, PA;
Lessons Learned Successful implementation for any practice change starts with communication and collaboration. Developing a strong team that encom41
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Dr Merrill Hunter; the entire surgical, intensivist, and respiratory teams; and most importantly, the amazing nurses in the ICU and the PCUs who cared for these patients with compassion every day. You are an amazing group of professionals.
7.
8. 9.
REFERENCES 1. Duffy M, Dresser S, Fulton J. Clinical Nurse Specialist Toolkit: A Guide for the New Clinical Nurse Specialist. New York, NY: Springer Publishing Company; 2009. 2. Lewandowski W, Adamle K. Substantive areas of clinical nurse specialist practice: a comprehensive review of the literature. Clin Nurse Spec. 2009;2:73–90. 3. Rose L, Dainty K, Jordan J, Blackwood B. Weaning from mechanical ventilation: a scoping review of qualitative studies. Am J Crit Care. 2014;23:e54–e70. 4. Konstantakos AK, Lee JH. Optimizing timing of early extubation in coronary artery bypass surgery patients. Ann Thorac Surg. 2000;69(6):1842–1845. 5. Reyes A, Vega G, Blancas R, et al. Early vs conventional extubation after cardiac surgery with cardiopulmonary bypass. CHEST. 1997;112:193–201. 6. Cheng D, Karski J, Peniston C, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use: a prospec-
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tive, randomized, controlled trial. Anesthesiology. 1996; 85:1300–1310. Cheng D, Karski J, Peniston C, et al. Fast track cardiac surgery pathways: early extubation, process of care, and cost containment. Anesthesiology. 1998;88:1429– 1433. Ask the Experts. Crit Care Nurse. 2006;26:3. Cheng D, Karski J, Peniston C, et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 1996;112:755–764. Rady MY, Thomas R. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med. 1999;27:340–347. Engoren M, Buderer N, Zacharias A, Habib R. Variables predicting reintubation after cardiac surgical procedures. Ann Thorac Surg. 1999;67:661–665. Cheng D. Pro: early extubation after cardiac surgery decreases intensive care unit stay and cost. J Cardiothorac Vasc Anesth. 1995;9:460–464. The Society of Thoracic Surgeons. http://www.sts.org. Accessed November 4, 2014. Smiths-Medical. http://www.smiths-medical.com/bronchial-hygiene/acapella. Accessed November 5, 2014. Rotondi A, Chelluri L, Sirio C, et al. Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;4:746–752.
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Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery Lisa M. Soltis, RN-BC, MSN, APRN, PCCN, CCRN-CSC, CCNS
ABSTRACT Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an
interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period. Keywords: cardiac surgery, clinical nurse specialist, extubation, nursing, outcomes, performance, performance improvement
H
ealth care reform continues to focus on improving patient outcomes while reducing costs. As clinical nurse specialists (CNSs), this focus on improved outcomes and reduced costs represents an opportunity to demonstrate our ability to affect both patient outcomes and fiscal responsibility. Within the CNS role, not only do we strive to improve patient outcomes, but we also evaluate processes and procedures to ensure best practice standards and patient safety, and we work to support clinical staff nurses to ensure they have the resources necessary to achieve quality outcomes. This article illustrates the impact a CNS can have on evaluating clinical interventions and care, improving system processes, and leading multidisciplinary teams to improve patient care outcomes.
gram or clinical area that coincides with his or her certification and expertise. The skills and knowledge required for this role include clinical expertise, evidence-based practice, collaboration, education, mentoring, and leadership to function as a change agent. These specialized skills and knowledge are used within 3 major areas of focus: nurses and nursing practice, patients and families, and organizational needs.1 The CNS is an integral part of the organization and brings a unique clinical focus to his or her practice. Clinical nurse specialists are particularly skilled at using evidence to drive performance improvement (PI) initiatives to improve patient outcomes and safety. Because CNSs may have many different
Background
Lisa M. Soltis is Clinical Nurse Specialist, Cardiothoracic Surgery, Sentara Heart Hospital, 600 Gresham Dr, Norfolk, VA 23457 ([email protected]).
Clinical Nurse Specialists
The author declares no conflicts of interest.
The CNS is an advanced practice nurse who serves as a clinical leader for a particular pro-
DOI: 10.1097/NCI.0000000000000070
35 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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responsibilities, their role can be confused with other roles within an organization. The CNS should understand the role and be able to articulate his or her responsibilities and integrate activities with other disciplines in the organization.2
heart surgery. The national average for patient extubation within 6 hours of surgery was 39.5%. Our data showed that the average number of patients who were extubated within that time frame was only 14.4% through April 2012. Another opportunity for improving quality of care was related to the number of patients who required transfer back to the cardiothoracic intensive care unit (CTICU) from the progressive care unit (PCU). Historically, approximately 5% of our patients after cardiac surgery required readmission to the CTICU. In April 2012, the data showed that the readmission rate had increased to more than 10% of all cardiac surgical patients. According to the STS database, the national benchmark for this standard was approximately 10% of all patients for this particular population. In addition, of those patients who required readmission to the CTICU, 60% had pulmonary complications, such as hypoxia and pulmonary edema. The ideal standard of care is to extubate patients within 6 hours after open heart surgery.5 Nurses are responsible for all aspects of patient care, including collaborating with respiratory care practitioners (RCPs) to facilitate weaning ventilator support.2,5 Programs that use fast track nursing extubation protocols have demonstrated no increase in morbidity or mortality rates and actually may improve patient outcomes.3–9
Reduction of Postoperative Complications
The clinical and organizational need to decrease intubation times and decrease respiratory complications in patients who have had open heart surgery is well documented in the literature.3–12 Early extubation after open heart surgery is a critical component of fast track protocols and can help reduce the development of pulmonary complications in the postoperative period while decreasing overall hospital length of stay (LOS). Cheng6,7 showed a 25% reduction in patient care costs as a result of early extubation protocols that led to a significant decrease in intensive care unit (ICU) LOS and a decrease in pulmonary complications. In addition, when patients experience complications, such as arrhythmias, hypotension, or hypoxia, in the postoperative period, they may require readmission to the ICU to manage their symptoms. A readmission can interrupt continuity of care for the patient as well as lead to increased hospital costs associated with the need for a higher level of care and monitoring.2,12 As part of a cardiothoracic surgery program, clinicians must submit specific data points for each patient to The Society of Thoracic Surgeons (STS). The mission of the STS is to enhance the ability of cardiothoracic surgeons to provide the highest-quality patient care through education, research, and advocacy. The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons.13 This professional organization reports data measures quarterly for each hospital in addition to comparative data to similar facilities and national benchmarks. While evaluating patient outcomes and morbidity data from the STS database reports for our institution, we noted an increase in LOS for our patients in comparison with similar facilities, as well as an increase in pulmonary complications in the postoperative period. Opportunities for improvement were related to prolonged intubation times in the immediate postoperative period in patients who had open
PI Plan Team Members and Setting
On the basis of best practice recommendations from the STS and review of our postoperative cardiac surgery data, our CTICU interdisciplinary team initiated a PI project to improve early extubation rates and to decrease the number of readmissions to the CTICU. This project was conducted in a 12-bed CTICU and a 40-bed PCU in a large medical center in the southeastern United States. This health system has more than 900 beds and performs more than 600 cardiac surgical procedures annually. The PI team was led by the CNS and the nurse manager for the CTICU. Initial team members for the CTICU project included nurses from the CTICU, the nurse manager from the cardiothoracic surgery unit, supervisor/educators, RCPs, and our STS data analyst. An analysis was completed to ascertain our strengths, weaknesses, 36
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opportunities for improvement, and threats/ barriers (SWOT analysis). This group was actively engaged as a team to improve care for our patients and focused on creating individualized plans of care based on patient needs, while maintaining a focus on patient safety. The goal was to increase the number of CTICU patients who were extubated in less than 6 hours to 40% by July 2013.
dure as well as the length of time on cardiopulmonary bypass, and availability of adequate personnel at shift change to facilitate weaning progression and assist with extubation. Actions were taken on the basis of analysis of the extubation evaluation forms. Inservices were conducted by the CNS and the data analyst with the anesthesiology team to ensure that patients would be adequately reversed from anesthetic agents at the time of transfer to the CTICU. The importance of early extubation was emphasized with the entire care team, including nursing and respiratory care services through inservices by the CNS. Many surgical patients were ready for extubation during shift changes, when RCPs were unavailable to assist because of handoff reporting. Respiratory care services made changes to their staffing patterns that allowed a lead therapist to be available to assist with extubation during shift changes. Having the lead therapist available for the nurses allowed continued progression of weaning efforts, regardless of time of day. The CNS and the nurse manager collected data weekly to provide team members with real-time data, which allowed timely evaluation of the weaning process. The CNS sent weekly updates to the entire nursing, respiratory, and leadership teams to communicate progress and to congratulate members of the team who achieved successful outcomes with their patients. This process helped keep the team engaged and gave time-sensitive feedback to nurses and RCPs.
Early Extubation
Between April 2012 and June 2012, the Cardiothoracic Surgery PI Project Team, led by the CNS, met biweekly to determine what interventions would improve our extubation rates. The clinical nurses and RCPs looked at our existing extubation protocol and discussed possible changes with the surgeons and intensivists to determine whether any modifications could be made. A new respiratory extubation protocol was developed to improve communication and weaning progression for clinical nurses and RCPs to implement. We researched potential risk factors for prolonged intubation and pulmonary complications to facilitate identification of high-risk patients.10,11 Clinical staff nurses also facilitated the process to have the new protocol presented at various internal meetings required for approval, which allowed the protocol to be embedded in the existing postoperative order set. Nurses noted that in certain cases, stabilizing oxygenation when the patient first came out of the operating room was a challenge. When they discussed these findings with the anesthesia team, the nurses discovered that different ventilator settings were used during surgery compared with the settings that were being used in the critical care unit. The CNS, nurse manager, surgeons, intensivists, and anesthesiologists discussed this discrepancy and decided to standardize the ventilator settings in both care environments to improve oxygenation and provide a consistent plan of therapy. The CNS and nurse manager created an extubation evaluation form for use by the clinical nurses when a patient could not be extubated within 6 hours. The CNS and the PI team evaluated the forms and identified possible barriers when targets for extubation were not achieved. Factors that contributed to longer intubation times included patients with a significant history of pulmonary disease, reversal of anesthetic agents upon transfer to the CTICU, the length of the surgical proce-
Readmission to the CTICU
Simultaneously, in April 2012, a subcommittee of the Cardiothoracic Surgery PI Project Team was formed to focus on post–cardiac surgery patient care management from the intermediate care perspective. This team also included the CNS, the CTICU manager, the PCU manager, the supervisor/educators, advanced practice nurses, physician assistants, respiratory care services, and clinical nursing staff from both the CTICU and the PCU. We had previously discovered in our data analysis that many of our patients experienced pulmonary complications in the postoperative period. Feedback from the clinical nurses indicated that many patients did not want to participate in their breathing exercises, some were reluctant to ambulate, and variation existed in the respiratory care treatments. The goal for this 37
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team was to decrease the number of patients who required readmission from the PCU back to the CTICU from 10% to 5% by July 2013. The team developed an evaluation tool to review each incidence when a patient required readmission to the CTICU. We evaluated the overall hospital course, preoperative comorbidities, surgical complications, CTICU course of care, date of transfer to the PCU, and any potential contributing factors that led to the development of complications. These data were reviewed with clinical nurses in both the CTICU and the PCU to help identify trends that may have contributed to the need for a higher level of care. In addition, respiratory care services developed an assessment tool that was used by the RCP that quantified the patient’s respiratory symptoms and history to determine the frequency of the patient’s treatments, such as nebulizer therapy and the use of a positive expiratory pressure mask with vibrations to help facilitate removal of pulmonary secretions. The use of the positive expiratory pressure mask has been found to significantly improve clearance of pulmonary secretions and is better tolerated by patients compared to traditional chest physiotherapy.14 Daily pulmonary rounding huddles were completed on all cardiac surgery patients in the PCU with the RCPs, the CTICU charge nurse, the PCU charge nurse or rounding nurse, the CNS, and the advanced care practitioners (acute care nurse practitioner or physician’s assistant). During these huddles, updates could be made to the patient’s treatment plan and communicated to the care team. During the daily respiratory huddles and discussions with respiratory care services, we discovered that orders for treatments every 6 hours were administered differently than orders for treatments 4 times daily, which would be administered in the morning, at lunch, at dinner, and before bedtime. Consequently, communication was significantly improved between disciplines through these daily rounds. The CNS, clinical staff nurses, and team members developed tools and algorithms to improve patient management when potential problems were identified after transfer to the PCU. These algorithms or flow diagrams for the PCU included critical thinking maps for hypotension, bradycardia, tachycardia, and hypoxia, which were the most common clinical findings observed in the postoperative
period. These tools were developed by the CNS, advanced practice care practitioners including acute care nurse practitioners and the surgical physician assistants, and the clinical staff nurses, and were created from existing treatment protocols and our standard postoperative orders. For example, the flow diagram for atrial arrhythmias illustrated a stepwise process for the nurse to follow in managing the patient, starting with the assessment process. These tools also improved communication among the care providers, so when the nurse called to notify the physician or midlevel provider, specific assessment findings were used during the communication process (see Figure 1). These flow diagrams also were used to educate clinical nurses on the PCU to facilitate critical thinking before calling the physician and requesting readmission to the CTICU. These algorithms were emphasized during inservices with the nurses to help improve critical thinking skills. The nurses became so familiar with the algorithms, they no longer needed to refer to the protocols but rather the concepts were incorporated into their plan of care and daily workflows, which led to a dramatic improvement in their critical thinking skills and improved focus on prevention of complications. The nurses also emphasized patient and family education on the importance of breathing exercises and ambulation to prevent possible complications. The PI team also decided to implement a rounding nurse role specific to our patient population to follow up on patients who were at high risk of return to the CTICU based on specific clinical criteria (Table 1). The rounding nurse or consulting nurse was assigned daily from the CTICU and was responsible for rounding on high-risk patients who had been transferred to the PCU the previous day, or who required continued follow-up. The goal of the CTICU consulting nurse would be to see the patient every 4 hours for the first 24 hours and continue to see the patient for longer than 24 hours if indicated. Indications for continued rounding included anytime the PCU requested assistance with changes in a patient’s condition or any patient who was not progressing according to accepted unit standards. This process was designed to ensure progression of care and additional ongoing assessment of the patient to ensure that no significant changes occurred in the patient’s condition 38
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Atrial Arrhythmias with Rapid Ventricular Response
CNS ROLE IN CA RD IAC SURGE RY IM P ROVE M E NT S
New A-Fib or A-Flutter
Check BP
Prepare ordered antiarrhythmics. Order ECG. Central line access?
Unstable, HR > 120
Stable, HR > 120
SBP < 90
SBP > 90
7A-7P Notify NP/PA. Notify CTICU consulting RN for CT Surgery patients. Call ICU rounding RN for all other patients if needed. 7P-7A Call Cardiology NP/PA if consult in place. Call surgeon if no orders in place.
Update BP, symptoms (if present), medications.
7A-7P Notify NP/PA Notify CTICU consulting RN for CT Surgery patients. Call ICU rounding RN for all other patients if needed.
Do Not Give Cardizem! Get the Code Cart
7P-7A Call Cardiology NP/PA if consult in place Notify CTICU consulting RN for CT Surgery patients. Call ICU rounding RN for all other patients if needed. Notify surgeon if patient does not respond to interventions, if needed.
Update BP, symptoms (if present), medications. Obtain stat K, Mg.
Give medications as ordered. Check labs as ordered (K, Mg, H&H)
Midlevel to order stat K, Mg, H&H if needed.
If midlevel or surgeon orders and patient has central access (no lung, liver or thyroid Hx) notify pharmacy for amiodarone bolus & drip.
Let NP/PA know VS, symptoms, and if central access is present.
Figure 1. Algorithm for management of atrial arrhythmias. A-fib indicates atrial fibrillation; A-flutter, atrial flutter; BP, blood pressure; CT, cardiothoracic; CTICU, cardiothoracic intensive care unit; ECG, electrocardiogram; H&H hemoglobin and hematocrit; HR, heart rate; Hx, history; ICU, intensive care unit; K, potassium; Mg, magnesium; NP, nurse practitioner; PA, physician assistant; SBP, systolic blood pressure; VS, vital signs. This figure is available in color in the article on the journal website, www.aacnadvancedcriticalcare.com, and the iPad.
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Extubaon in Less Than 6 hours
Table 1: High-Risk Criteria for Readmission to the ICU
Postintervention
Percentage of Extubations < 6 hours
80.00%
Prolonged Intubation time > 48 h History of COPD, impaired pulmonary function, poor CDB effort, incentive spirometer < 1000 mL Increased oxygenation needs, use of high flow oxygen Complicated postoperative course Chest radiograph with atelectasis
70% 70.00% 60.00%
63% Preintervention
48%
50.00%
28.60%
30.00% 20.00%
14.40%
10.00% 0.00% 2012 Q1
2012 Q3-Q4
2013 Q1
2013 Q2
2013 Q3
Percentage 14.40% 28.60%
48%
63%
70%
Decreased oxygen saturation levels < 92% Decreased ejection fraction < 25%
Goal was to increase # of extubaons to > 40%
40.00%
Date/Time Frame
Vasoactive medications within 4 h of transfer
Figure 2. Graph showing progress of increasing extubations in less than 6 hours. This figure is available in color in the article on the journal website, www.aacnadvanced criticalcare.com, and the iPad.
Significantly impaired mobility Impaired renal function with oliguria, elevated BUN/creatinine Altered level of consciousness, confusion Any clinical condition that would give the nurse cause for concern
decreased from 22.8 to 11.1 hours, and the reintubation rate remained consistent at 2.9%, below the national average of 3.7%. During the same time period, no failed extubations required emergent reintubation. Our partnership to improve patient management in the intermediate care environment resulted in reduced returns to the ICU to 2.6% (down from 7.4%) (see Figure 4). Returns related to pulmonary complications, such as pulmonary edema or hypoxia, decreased to 27% (from 60%). In addition, patients with any pulmonary complication in the postoperative period, regardless of the need for readmission to the ICU, also decreased to 11% (from 21.2%).
Abbreviations: BUN, blood urea nitrogen; CDB, cough/deep breathe; COPD, chronic obstructive pulmonary disease; ICU, intensive care unit.
after the patient left the CTICU. Early assessment and recognition of changes in the patient’s condition ensured earlier intervention to improve patient outcomes. The consulting nurse was already caring for patients in the CTICU; therefore, no additional cost to the unit was incurred in implementing this role. The CNS and the manager completed in-depth data collection for case reviews of each patient who was readmitted to the CTICU. These data were then shared at staff meetings for the benefit of all nurses and practitioners involved in patient care. Facilitation of discussion during the case reviews was led by the CNS and the nurse manager to ensure appropriate focus on teachable moments and learning opportunities. These discussions also generated ideas for future management of similar situations if they occurred again.
Secondary outcome observed but not part of original goals. Naonal average was 10%
Outcomes Our partnership to promote early extubation resulted in a significant increase in the number of patients extubated in less than 6 hours from a baseline of 14.4% to 48% (see Figure 2). A secondary outcome achieved with this project resulted in a decrease in prolonged intubations (> 24 hours) to 7% (down from 15.7%) (see Figure 3). Mean initial ventilation hours
Prolonged Intubations >24 hours
Prolonged Intubaons > 24 hours
18.00% 16.00%
Preintervention 15.70% Postintervention
14.00% 11.50%
12.00% 10.00%
8.80%
8%
8.00%
7% 5%
6.00% 4.00% 2.00% 0.00%
Q2 2012
Q3 2012
% >24 hrs 15.70% 11.50%
Q4 2012
Q1 2013
Q2 2013
Q3 2013
8.80%
8%
7%
5%
Date/Time Frame
Figure 3. Graph showing prolonged intubations. This figure is available in color in the article on the journal website, www.aacnadvanced criticalcare.com, and the iPad. 40
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passes the entire scope of the patient experience is critical to success. As CNSs, our role can facilitate that process through the various aspects of our training and education. As evidence-based practice experts, we must ensure that best practice standards are met through literature review and that clinical standards established by governing organizations are clearly understood and implemented. Clinical experts should communicate the standards set forth by the STS and ensure that all members of the PI team and clinical nurses are aware of the appropriate definitions and expectations of care. Everyone involved with this project was engaged and excited about improving our patient outcomes, so the need to change any unit-based cultural changes/beliefs was moot.
Readmissions to CTICU from PCU Preintervention
8.00%
7.40%
Percentage of Returns
7.00% 6% 6.00%
6%
Postintervention
5.40%
5.00% 4.20% 4.00% 3.00%
2.60% 1.80%
2.00% 1.00% 0.00%
Returns to ICU
2012 Q1
2012 Q2
2012 Q3
2012 Q4
2013 Q1
2013 Q2
2013 Q3
7.40%
6%
5.40%
6%
4.20%
2.60%
1.80%
Date/Time Frame
Figure 4. Graph showing readmissions to the ICU. CTICU indicates cardiothoracic intensive care unit; ICU, intensive care unit; PCU, progressive care unit. This figure is available in color in the article on the journal website, www.aacnadvancedcritical care.com, and the iPad.
Summary This PI project to decrease extubation times in patients who had cardiac surgery allowed us to successfully demonstrate that early extubation leads to improved patient outcomes, which in turn can lead to a decreased LOS and decreased hospital costs. Using an interdisciplinary approach, patient management and patient flow were maximized by achieving a decrease in returns to the CTICU as well. Keeping the team members aware of our progress helped maintain engagement and enthusiasm for changing and improving our practice. The CNS and the clinical nurses were continually providing feedback to each other and to leadership, which also helped keep the team motivated. Being able to articulate what we do as CNSs, and to tie those activities to patient outcomes, is vital to ensuring that the CNS role will continue to thrive.
The financial impacts of these improvements were astounding. We achieved a reduction in LOS by 2.2 days during this project. When averaged over the number of cardiac surgery cases completed, this change equated to an approximate reduction in cost of more than $2 million. This cost-reduction estimate did not include the decreased need for additional patient care resources, the reduction in expenses related to ventilatory care and support, or the reduction in nursing care hours. We achieved improved patient flow by allowing earlier transfers to the PCU, which increased the availability of ICU rooms to ensure that the operating room could transfer patients in a timely fashion. Qualitative studies have shown that common themes from the patient perspective during ventilatory weaning include physical discomfort, impaired communication capabilities, and fear/anxiety related to the weaning process.3,15 Therefore, earlier extubation also can result in improved psychological well-being for patients. We observed that patients’ families were very happy to see their loved ones progress so quickly and safely toward discharge home.
Acknowledgments I thank everyone involved with this project, especially Ellen Wheaton, RN, BSN, CCRN, nurse manager. Her undying commitment to patient safety and quality outcomes is unparalleled, and she has been an amazing mentor. Other members of the team included Thomas Del Corro, RN; Kelly Thompson-Brazill, RN, MSN, ACNP-BC, CCRN-CSC, FCCM; Melissa Chapin, RN, BSN, CCRN; Wanda Adams, RN, BSN, CCRN; Dana Earle, RN, BSN, CCRN; Sharon McDonald, RN, BSN, CCRN; Sarah Hale, RN, PCCN; Gina McConnell, RN, CCRN; Sandra Vanscoy, RN, BSN, NE-BC; Megan Swink, RN, PCCN; Patricia Jones, RN, PCCN; Wayne Warden, RCP; Paul Keene, RCP; Jen White, RCP; Jeffrey Lamphere, PA;
Lessons Learned Successful implementation for any practice change starts with communication and collaboration. Developing a strong team that encom41
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Dr Merrill Hunter; the entire surgical, intensivist, and respiratory teams; and most importantly, the amazing nurses in the ICU and the PCUs who cared for these patients with compassion every day. You are an amazing group of professionals.
7.
8. 9.
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