Clinical Nurse SpecialistA Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Feature Article The Clinical Nurse Specialist as Resuscitation Process Manager Mary Elizabeth Schneiderhahn, MSN, RN, ACNS-BC n Anne Folta Fish, PhD, RN, FAHA
Purpose/Objectives: The purpose of this article was to describe the history and leadership dimensions of the role of resuscitation process manager and provide specific examples of how this role is implemented at a Midwest medical center. Background: In 1992, a medical center in the Midwest needed a nurse to manage resuscitation care. Rationale: This role designation meant that this nurse became central to all quality improvement efforts in resuscitation care. The role expanded as clinical resuscitation guidelines were updated and as the medical center grew. The role became known as the critical care clinical nurse specialist as resuscitation process manager. This clinical care nurse specialist was called a manager, but she had no direct line authority, so she accomplished her objectives by forming a multitude of collaborative networks. Description: Based on a framework by Finkelman, the manager role incorporated specific leadership abilities in quality improvement: (1) coordination of medical center-wide resuscitation, (2) use of interprofessional teams, (3) integration of evidence into practice, and (4) staff coaching to develop leadership. Outcome: The manager coordinates resuscitation care with the goals of prevention of arrests if possible, efficient and effective implementation of resuscitation protocols, high quality of patient and family support during and after the resuscitation event, and creation or revision of resuscitation policies for in-hospital and for ambulatory care areas. The manager Author Affiliations: Critical Care Clinical Nurse Specialist (Ms Schneiderhahn), Missouri Baptist Medical Center, St Louis, and Associate Professor of Nursing (Dr Fish), University of MissouriYSt Louis in a collaborative clinical partnership with Missouri Baptist Medical Center, St Louis. The authors report no conflicts of interest. Correspondence: Mary Elizabeth Schneiderhahn, MSN, RN, ACNS-BC, Missouri Baptist Medical Center, 245 Elm Ave, St Louis, MO 63122 ([email protected]). DOI: 10.1097/NUR.0000000000000080
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designs a comprehensive set of meaningful and measurable process and outcome indicators with input from interprofessional teams. The manager engages staff in learning, reflecting on care given, and using the evidence base for resuscitation care. Finally, the manager role is a balance between leading quality improvement efforts and coaching staff to implement and sustain these quality improvement initiatives. Conclusion: Revisions to clinical guidelines for resuscitation care since the 1990s have resulted in medical centers developing improved resuscitation processes that require management. The manager enhances collaborative quality improvement efforts that are in line with Institute of Medicine recommendations. Implications: The role of resuscitation process manager may be of interest to medical centers striving for excellence in evidence-based resuscitation care. KEY WORDS: leadership, quality improvement, resuscitation
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bout one-half million Americans experience a cardiac arrest each year, and approximately 15% survive the event.1 The success rate of resuscitation in the hospital ranges from 15% to greater than 20% and is linked to the quality of cardiopulmonary resuscitation.2 Today, inpatient resuscitation care is viewed as holistic, focusing on preventing the arrest if possible, performing cardiopulmonary resuscitation using medications and supportive devices according to established evidence-based protocols, and providing family support during and after the resuscitation event. Nurses are involved in all aspects of resuscitation care.3 The purpose of this article was to describe the history and leadership dimensions of the role of the critical care clinical nurse specialist as resuscitation process manager (referred to here as the manager) and provide specific examples of how this role is implemented at a Midwest medical www.cns-journal.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Feature Article center. Although the nurse is called a manager, he/she has no direct line authority, so he/she must accomplish his/her objectives by forming a multitude of collaborative networks. The history of the manager role parallels advances in clinical resuscitation guidelines. The leadership dimensions that are presented are based on the Finkelman4 leadership quality improvement framework.
HISTORY In 1992, a consensus panel, the International Liaison Committee on Resuscitation, was formed and included the American Heart Association (AHA), the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Councils of Southern Africa, the Resuscitation Councils of Asia, and the Inter American Heart Foundation. At that time, nurses at a Midwest medical center reported resuscitation-related problems to the night supervisor, but this process was not efficient, and follow-up and making changes to improve resuscitation care were slow. There was no clear mechanism in place to distribute resuscitation-related findings and implement new processes. Out of this circumstance, the medical center chose to optimize resuscitation care by designating a manager, whose role emerged and grew as the medical center expanded. In 1992, the manager tabulated resuscitation statistics, improved the efficiency of mock code drills, and coordinated research studies on the first automatic external defibrillators (AEDs). By the 2000s, based on the Agency for Health Care Policy and Research guidelines, the manager defined a set of data indicators about resuscitation care. The manager used relational databases to record these indicators and generated periodic reports. In addition, the manager reevaluated orientation of hospital personnel regarding AED use, made resuscitation an integrated part of competency requirements, and used manikins and AED simulators during orientation. By 2003, the role of the manager expanded to include leading the coordination and monitoring of resuscitation processes for the entire medical center for performance improvement purposes. Reporting adherence to resuscitation processes and reporting outcomes to unit-based physicians, medical directors, and quarterly to hospital administrators became more systematized. The role, designed to be broad in scope, involved the individual patient, family, nursing staff, many other members of the health care team, and medical center administrators. From 2010 to today, following the publication of the AHA consensus resuscitation guidelines,2,5Y7 the manager updates medical center policies and procedures and monitors interdisciplinary actions and reactions in simulated and real-time resuscitation scenarios. For example, the manager creates, implements, and evaluates action plans to gather 344
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data on difficult intubations and orients medical center personnel to difficult-to-intubate scopes and capnography.
LEADERSHIP DIMENSIONS OF THE MANAGER ROLE In the context of medical centers today, with their changing technology and care priorities, the manager has an essential and stabilizing role. The manager updates nursing staff, unit-based nurse educators, and others on evidence-based resuscitation, new and advanced equipment, and clinical practice advances in the field. Based on the clinical nurse specialist quality improvement leadership framework by Finkelman,4 specific dimensions of the manager role are (1) coordination of medical center-wide resuscitation quality improvement, (2) use of interprofessional teams, (3) integration of evidence into practice, and (4) staff coaching to develop leadership. Examples about leadership are provided for each dimension. Leadership Dimension 1: Coordination of Medical Center-Wide Quality Improvement The manager coordinates medical center-wide quality improvement of resuscitation care processes and identifies and presents ways to make improvements.4 Several examples of process and outcome indicators and ongoing quality improvement projects follow. The manager initiates and updates resuscitation process and outcome indicators. A set of such indicators is presented in the Table. According to the AHA consensus resuscitation guidelines,2,5Y7 no single outcome is appropriate to measure results of resuscitation, and no tool or measure is seen as a criterion standard. Because the perceptions of success and failure of resuscitation are too broad, tracking specific process and outcome indicators is important. The indicators focus on the individual, family, and medical center levels of care and are tracked monthly and from year to year. Medical centers can use indicators such as the ones in the Table or add new measures as they are mandated or become important for care. For example, all these indicators are based on AHA guidelines,2,5Y7 except the number of difficult intubations, which is tracked at this Midwestern medical center to facilitate quality improvement processes. Although some hospitals have outside data management companies to track their outcomes against benchmarks, engaging this service might not be feasible during times of fiscal constraint. The manager’s role is central to medical center-wide resuscitation quality improvement. The Figure illustrates just how central the manager’s role is in communicating among the many layers of staff, committees, councils, and boards at the medical center. Results of process and outcome resuscitation indicators are communicated by the manager monthly to the director of Quality and Patient Safety, then to the Operations Performance and Improvement Council, and then on to the Board of the Medical Center. Specifically, November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table. Process and Outcome Indicators of
Resuscitation Care at the Individual, Family, and Medical Center Levels Individual Patient Level Process indicators Code personnel response as planned Equipment concerns Supplies available and adequate Process indicators specific to ventricular fibrillation or ventricular tachycardia Ventilation begun G1 min Compressions begun G3 min prior to 2011, G1 min 2011 and after Shocks initiated G3 min prior to 2011, G2 min 2011 and after Invasive airway established G5 min Epinephrine administered G5 min Process indicators specific to pulseless electrical activity or asystole Ventilation begun G1 min Compressions begun G1 min Invasive airway established G5 minutes Epinephrine administered G5 min Outcome indicators Survival postresuscitation Survival to hospital discharge
Family Level Process indicators Familyoffered option to be present and rationale noted if excluded from being present Family accepted offer Code stopped by family request Palliative care or organ transplant services as needed Family debriefing after witnessed resuscitation Outcome indicators Family_s response to witnessed resuscitation
Medical Center Level Process indicators Systems that support regular communication between clinical personnel and administrators Patterns of outstanding and less than outstanding implementation of procedures Use and sustainability of quality, evidence-based procedures Outcome indicators (totals by month and year) Resuscitations Ventricular fibrillation or ventricular tachycardia events Pulseless electrical activity or asystole events Events in intensive care units Automated external device utilization Survival postresuscitation Survival to hospital discharge Intubations described as difficult
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these data are used to generate graphs and benchmarking materials. A process was created to signal the Department of Quality and Patient Safety following pulseless events, to interview frontline staff to assess the series of patient events leading up to the pulseless event. Rich information is obtained from these interviews, resulting in numerous quality improvement projects. Frequently, further evaluation by the manager leads to policy/procedure revision as well as planned educational initiatives. Monthly, all pulseless events are reviewed by the manager and critical care medical director. Significant events are communicated to the Committee on Mortality and Morbidity for further exploration and comment. The communication link the manager provides among the varied councils, committees, and departments is crucial to the success of the resuscitation program. The planned structure allows for the ability to solicit feedback from as well as to communicate with and reinforce process changes to bedside nurses, multidisciplinary rapid response team (RRT) members, unit-based nurse educators, unit practice councils, Critical Care Performance Improvement Committee, and the Nursing Executive and the Quality and Safety Councils. The Critical Care Performance Improvement Committee, led by the manager and the critical care medical director, allows for high intensive care unit (ICU) staff nurse participation and important contributions to changes in patient careYrelated resuscitation practices. These meeting minutes are disseminated medical center-wide to administrators, clinical department directors, intensivists, and ICU staff nurses. The manager initiates and monitors the sustainability of several successful ongoing medical center-wide projects, such as the following: n Improving Handoffs Project. The manager implements and evaluates policies and action plans to coordinate handoffs of resuscitated, but yet comatose, patients who on admission to the emergency department undergo therapeutic hypothermia. These handoffs are often challenging because they are ongoing as the patient moves from the emergency department to computed tomography scan, the cardiac catheterization laboratory, the ST-segment elevation myocardial infarction unit, and/or the ICU. n Improving 911 Versus 555 (in Hospital) Emergency Call Project. The manager continuously refines the medical center’s comprehensive emergency management policy as it relates to resuscitation including the use of 555 (in house) versus 911 (community emergency medical services) for present and ever-expanding areas within medical centers including lobbies, new parking garages, and new wings containing a patchwork of rented and medical center-run physician offices. n Improving Recognition of Patient Deterioration Project. The manager coordinates the setting up of a system to place in each patient’s room a poster with a phone www.cns-journal.com
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FIGURE. Resuscitation process manager in a central role coordinating medical center-wide resuscitation care.
number for the family to call if they are concerned that their loved one is having difficulty. n Optimizing Resuscitation Equipment Use Project. The manager is in charge, medical center wide, of overseeing the procurement, location, storage, and appropriate use of all resuscitation-related devices and carts, including special difficult-to-intubate scopes, defibrillators, and capnography machines. The manager also disseminates information from webinars and industry representatives about use of this equipment. Specifically, the manager periodically evaluates the effectiveness of AEDs, tracks their use, problem solves, remedies any problems that arise with AED use, and revises evidencebased medical center policies about AEDs. Also at times the manager has been called upon to resolve, with a team, medical center-wide policy questions such as whether AEDs located in the medical center should be available for the use of staff only or for use by the general public in an emergency. Leadership Dimension 2: Use of Interprofessional Teams The manager effectively uses interprofessional teams to achieve identified improvement goals.4 The manager meets yearly in January with a respiratory therapist, physician assistant, physician, and nurse to discuss trends in resuscitation indicators from the previous year and subsequently meets with the Critical Care Performance Improvement team consisting of the chief ICU physician, other ICU physicians, staff nurses, and physical and respiratory therapists. They develop and initiate an action plan annually or any time 346
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there is an upward trend in the resuscitation data indicators. The manager then contacts administration about the need for equipment to carry out the action plan. For example, recently, data on the difficult-to-intubate resuscitation indicator led the medical center to buy more difficult intubation scopes. The manager updates policies, procedures, and protocols that govern the provision of CPR services and provides a mechanism for teaching and implementing high overall resuscitation quality, so that individual staff and teams function more effectively. Leadership Dimension 3: Integration of Evidence Into Practice The manager integrates evidence into practice to facilitate quality improvement .4 For example, the manager measures resuscitation outcomes and creates evidence-based forms (Rapid Response Team Form, Resuscitation Record) based on evidence-based AHA guidelines.2,5Y7 The critical roles and goals of the manager are in line with AHA standards of resuscitation care2,5Y7 in the areas of CPR-related devices, activation of RRTs, life support, family presence at resuscitation, and use of palliative care team and organ transplant services. The manager keeps up with changes in guidelines and in turn facilitates revisions to in-house protocols and procedures impacting resuscitation care such as medication sequencing and timing of defibrillation. The manager is a leader in evidence-based practice (EBP). The manager serves as a role model by publishing and presenting at conferences. He/she facilitates staff nurse attendance at EBP conferences and active participation during November/December 2014
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internet resuscitation webcasts. The manager collaborates with the medical center’s EBP Council to conduct EBP projects on resuscitation (such as understanding advantages of new types of equipment for the medical center). This manager also suggests how those interested in resuscitation can get involved with performance improvement or EBP or research projects to enhance resuscitation through shared governance nursing councils. Leadership Dimension 4: Staff Coaching to Develop Leadership The manager coaches staff to develop leadership at the bedside.4 He/she coaches the RRT nurses. The manager attends RRT meetings quarterly and encourages those nurses to talk about resuscitation and EBP-related resuscitation topics about processes or equipment used, such as capnography during a pulseless event. As the clinical leader during RRT calls, the RRT nurses must feel confident in their knowledge base and with their skills. The manager coaches the RRT staff as they monitor trends in the resuscitation indicators and implement action plans. To strengthen teambuilding skills, the manager may implement approaches used in advanced cardiac life support to facilitate leadership at the bedside. Nursing staff throughout the medical center are either directly or indirectly coached by the manager to recognize early signs of hemodynamic distress, call for the RRT, and begin to deliver competent emergency care to attempt to prevent further deterioration of the patient. Preparing and monitoring RRT for action, evaluating the quality of the response and the team’s perception of that quality, aiding intransition to computerized documentation for RRT care, monitoring processes and how well RRTs follow protocols, and facilitating team building are important roles for the manager alone or in conjunction with unit-based nurse educators. The manager might mentor staff on an evidence-based project on family-witnessed resuscitation. Through the development and completion of staff questionnaires, staff feelings on this topic can be explored that can lead to the creation of a successful protocol on family presence during a code situation. Evaluation items could include whether the family was given the option to be present, impression of the family’s response, debriefing of staff, and debriefing the family. Ongoing evaluation of this program can be accomplished with coaching from the manager. The manager may be called on to coach those writing policies about the initiation of palliative care and organ transplant. The timing of a palliative care specialist consultation and/or organ transplant services is important. Staff nurses and RRTs can be surveyed about their role in accessing these services, as well as approaches to provide the family with as positive an experience as possible. The manager also discusses case scenarios about the process of Clinical Nurse Specialist
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withdrawal of care, hospice options, and obtaining a donot-resuscitate order if that is the family’s choice. Although all palliative care situations related to resuscitation are stressful, some are more stressful than others. These situations require long-term follow-up support by the manager. As part of coaching, the manager invites staff to convey stories about situations in end-of-life care they have encountered as part of resuscitation. The manager coaches unit-based educators to become confident in running mock codes. These mock codes are conducted annually as part of yearly competencies using manikins or simulators and, depending on the requests, may be held as often as every 3 months. The shared governance unit practice councils may request mock codes be run at their meetings. Unit secretaries and physical and occupational therapists may request to be involved because they sometimes are present when the patient arrests, and they also want to know what to do in an emergency, how to get the crash cart, and what the terms mean. The manager recognizes that some nurses want to be mock code coordinators and unit champions for resuscitation; this enthusiasm can be rewarded if the medical center has a career ladder or similar system that recognizes outstanding leadership and initiative.
CONCLUSIONS Revisions to clinical guidelines for resuscitation care since the 1990s have resulted in medical centers developing improved resuscitation processes and outcomes that require management. The Institute of Medicine report, Health Professions Education: A Bridge to Quality,8 emphasizes leadership and recommends expanding opportunities for nurses to lead and diffuse collaborative improvement efforts, especially in collaborating to disseminate knowledge and create sustainable change. The resuscitation process manager role is very much in line with the institute’s recommendation. The manager has taken on a central role in coordinating the monitoring of a comprehensive list of evidence-based process and outcome quality indicators, utilizing interprofessional teams, integrating evidence into practice, and coaching staff. Outcome data on survival of event and survival to discharge at the Midwest medical center used as an example have suggested improvements over the years. In addition, bedside staff engagement in clinical resuscitation improvement initiatives, a core Magnet principle, is now common place. For example, in some locations, staff nurses have become so confident with initial responder basic life support priorities and responsibilities that they have assumed the coordination and delivery of mock codes. This demonstrates not only increased staff knowledge but also staff creating a work environment that supports excellence in nursing. Finally, various needs assessments continue to www.cns-journal.com
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Feature Article reflect the staff’s strong interest in mock codes and in the care of the deteriorating patient. Facilitating factors as well as barriers have been identified as they relate to implementing the manager role over time. Because of regulatory standards referencing improvement processes specific to emergency care, administrative and frontline management support continued to be strong. Ancillary department leaders and staff in multidisciplinary services at the medical center, including pharmacy and social work, had 1 point person to go to for all questions about resuscitation care. Collaborative relationships were easily established between the manager and many ancillary departments as a result of their work together on other critical care or patient-centered initiatives and projects. Recently, to benefit patient care, the decision was made collaboratively to purchase more difficult intubation equipment. Initiating any new role includes barriers of some kind. Three barriers are particularly noteworthy. First, a barrier was inconsistent management support from ancillary departments because of frequent changes in managers and staff as a result of organizational restructuring. Second, the implementation of a variety of projects simultaneously competed for the manager’s time and caused her to have to reset priorities often. Finally, the manager’s authority comes from expert knowledge, which does not include line authority, which presents some challenges with staff accountability. The manager worked at helping others to be part of the solution as problem situations in resuscitation care arose, as well as helping them be accountable for current standards of care. The major objective of the manager role is leadership in quality improvement. The framework by Finkelman4 is seen as appropriate to describe leadership aspects of this successful role at a medical center in the Midwest .The fact that the manager at the Midwest medical center was already a clinical nurse specialist meant that she already had autonomy to facilitate change and study the problem situations that emerged related to resuscitation care in order to find solutions; many situations are compelling and require immediate action or attention. By implementing this role
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using a clinical nurse specialist, hospitals are likely to experience a seamless process where the manager designs the ‘‘standard work’’ and possesses the ability to navigate among many different levels within the organizational structure. The clinical nurse specialist in this role uses a systems approach in his/her thinking to achieve the necessary goals. The clinical nurse specialist also has a clear understanding of the organizational pressures to deliver expert clinical care in the most efficient manner. Finally, he/she is well equipped to innovate and explore a multitude of options to deliver best practice resuscitation care. Designating a clinical nurse specialist in the resuscitation process manager role may be of interest to hospitals striving for excellence in evidencebased resuscitation care.
References 1. American Heart & Stroke Association. Top ten things to knowVCPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital. Published 2013. http://circ.ahajournals.org/ lookup/doi/10.1161/CIR.0b013e31829d8654. Accessed October 30, 2013. 2. Meaney PA, Bobrow BJ, Mancini ME, et al. CPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Published 2013. http://circ.ahajournals.org/content/early/2013/06/ 25/CIR.0b013e31829d8654. Accessed August 28, 2014. 3. Clements A, Curtis K. What is the impact of nursing roles in hospital patient resuscitation? Australas Emerg Nurs J. 2012;15:108Y115. 4. Finkelman A. The clinical nurse specialist: leadership in quality improvement. Clin Nurse Spec. 2013;January/February:31Y35. 5. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Published 2010. http://circ.ahajournals.org/content/ 122/16_suppl_2/S250. Accessed October 30, 2013. 6. Becker LB, Aufderheide TP, Geocadin RG, et al. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association. Circ. 2011;124(19):2158Y2177. 7. Mancini ME, Soar J, Bhanji F, et al. Part 12: education, implementation, and teams: international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Published 2010. http://circ.ahajournals .org/content/122/16_suppl_2/S539. Accessed October 30, 2013. 8. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington DC: The National Academies Press; 2003.
November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Feature Article The Clinical Nurse Specialist as Resuscitation Process Manager Mary Elizabeth Schneiderhahn, MSN, RN, ACNS-BC n Anne Folta Fish, PhD, RN, FAHA
Purpose/Objectives: The purpose of this article was to describe the history and leadership dimensions of the role of resuscitation process manager and provide specific examples of how this role is implemented at a Midwest medical center. Background: In 1992, a medical center in the Midwest needed a nurse to manage resuscitation care. Rationale: This role designation meant that this nurse became central to all quality improvement efforts in resuscitation care. The role expanded as clinical resuscitation guidelines were updated and as the medical center grew. The role became known as the critical care clinical nurse specialist as resuscitation process manager. This clinical care nurse specialist was called a manager, but she had no direct line authority, so she accomplished her objectives by forming a multitude of collaborative networks. Description: Based on a framework by Finkelman, the manager role incorporated specific leadership abilities in quality improvement: (1) coordination of medical center-wide resuscitation, (2) use of interprofessional teams, (3) integration of evidence into practice, and (4) staff coaching to develop leadership. Outcome: The manager coordinates resuscitation care with the goals of prevention of arrests if possible, efficient and effective implementation of resuscitation protocols, high quality of patient and family support during and after the resuscitation event, and creation or revision of resuscitation policies for in-hospital and for ambulatory care areas. The manager Author Affiliations: Critical Care Clinical Nurse Specialist (Ms Schneiderhahn), Missouri Baptist Medical Center, St Louis, and Associate Professor of Nursing (Dr Fish), University of MissouriYSt Louis in a collaborative clinical partnership with Missouri Baptist Medical Center, St Louis. The authors report no conflicts of interest. Correspondence: Mary Elizabeth Schneiderhahn, MSN, RN, ACNS-BC, Missouri Baptist Medical Center, 245 Elm Ave, St Louis, MO 63122 ([email protected]). DOI: 10.1097/NUR.0000000000000080
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designs a comprehensive set of meaningful and measurable process and outcome indicators with input from interprofessional teams. The manager engages staff in learning, reflecting on care given, and using the evidence base for resuscitation care. Finally, the manager role is a balance between leading quality improvement efforts and coaching staff to implement and sustain these quality improvement initiatives. Conclusion: Revisions to clinical guidelines for resuscitation care since the 1990s have resulted in medical centers developing improved resuscitation processes that require management. The manager enhances collaborative quality improvement efforts that are in line with Institute of Medicine recommendations. Implications: The role of resuscitation process manager may be of interest to medical centers striving for excellence in evidence-based resuscitation care. KEY WORDS: leadership, quality improvement, resuscitation
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bout one-half million Americans experience a cardiac arrest each year, and approximately 15% survive the event.1 The success rate of resuscitation in the hospital ranges from 15% to greater than 20% and is linked to the quality of cardiopulmonary resuscitation.2 Today, inpatient resuscitation care is viewed as holistic, focusing on preventing the arrest if possible, performing cardiopulmonary resuscitation using medications and supportive devices according to established evidence-based protocols, and providing family support during and after the resuscitation event. Nurses are involved in all aspects of resuscitation care.3 The purpose of this article was to describe the history and leadership dimensions of the role of the critical care clinical nurse specialist as resuscitation process manager (referred to here as the manager) and provide specific examples of how this role is implemented at a Midwest medical www.cns-journal.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
343
Feature Article center. Although the nurse is called a manager, he/she has no direct line authority, so he/she must accomplish his/her objectives by forming a multitude of collaborative networks. The history of the manager role parallels advances in clinical resuscitation guidelines. The leadership dimensions that are presented are based on the Finkelman4 leadership quality improvement framework.
HISTORY In 1992, a consensus panel, the International Liaison Committee on Resuscitation, was formed and included the American Heart Association (AHA), the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Councils of Southern Africa, the Resuscitation Councils of Asia, and the Inter American Heart Foundation. At that time, nurses at a Midwest medical center reported resuscitation-related problems to the night supervisor, but this process was not efficient, and follow-up and making changes to improve resuscitation care were slow. There was no clear mechanism in place to distribute resuscitation-related findings and implement new processes. Out of this circumstance, the medical center chose to optimize resuscitation care by designating a manager, whose role emerged and grew as the medical center expanded. In 1992, the manager tabulated resuscitation statistics, improved the efficiency of mock code drills, and coordinated research studies on the first automatic external defibrillators (AEDs). By the 2000s, based on the Agency for Health Care Policy and Research guidelines, the manager defined a set of data indicators about resuscitation care. The manager used relational databases to record these indicators and generated periodic reports. In addition, the manager reevaluated orientation of hospital personnel regarding AED use, made resuscitation an integrated part of competency requirements, and used manikins and AED simulators during orientation. By 2003, the role of the manager expanded to include leading the coordination and monitoring of resuscitation processes for the entire medical center for performance improvement purposes. Reporting adherence to resuscitation processes and reporting outcomes to unit-based physicians, medical directors, and quarterly to hospital administrators became more systematized. The role, designed to be broad in scope, involved the individual patient, family, nursing staff, many other members of the health care team, and medical center administrators. From 2010 to today, following the publication of the AHA consensus resuscitation guidelines,2,5Y7 the manager updates medical center policies and procedures and monitors interdisciplinary actions and reactions in simulated and real-time resuscitation scenarios. For example, the manager creates, implements, and evaluates action plans to gather 344
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data on difficult intubations and orients medical center personnel to difficult-to-intubate scopes and capnography.
LEADERSHIP DIMENSIONS OF THE MANAGER ROLE In the context of medical centers today, with their changing technology and care priorities, the manager has an essential and stabilizing role. The manager updates nursing staff, unit-based nurse educators, and others on evidence-based resuscitation, new and advanced equipment, and clinical practice advances in the field. Based on the clinical nurse specialist quality improvement leadership framework by Finkelman,4 specific dimensions of the manager role are (1) coordination of medical center-wide resuscitation quality improvement, (2) use of interprofessional teams, (3) integration of evidence into practice, and (4) staff coaching to develop leadership. Examples about leadership are provided for each dimension. Leadership Dimension 1: Coordination of Medical Center-Wide Quality Improvement The manager coordinates medical center-wide quality improvement of resuscitation care processes and identifies and presents ways to make improvements.4 Several examples of process and outcome indicators and ongoing quality improvement projects follow. The manager initiates and updates resuscitation process and outcome indicators. A set of such indicators is presented in the Table. According to the AHA consensus resuscitation guidelines,2,5Y7 no single outcome is appropriate to measure results of resuscitation, and no tool or measure is seen as a criterion standard. Because the perceptions of success and failure of resuscitation are too broad, tracking specific process and outcome indicators is important. The indicators focus on the individual, family, and medical center levels of care and are tracked monthly and from year to year. Medical centers can use indicators such as the ones in the Table or add new measures as they are mandated or become important for care. For example, all these indicators are based on AHA guidelines,2,5Y7 except the number of difficult intubations, which is tracked at this Midwestern medical center to facilitate quality improvement processes. Although some hospitals have outside data management companies to track their outcomes against benchmarks, engaging this service might not be feasible during times of fiscal constraint. The manager’s role is central to medical center-wide resuscitation quality improvement. The Figure illustrates just how central the manager’s role is in communicating among the many layers of staff, committees, councils, and boards at the medical center. Results of process and outcome resuscitation indicators are communicated by the manager monthly to the director of Quality and Patient Safety, then to the Operations Performance and Improvement Council, and then on to the Board of the Medical Center. Specifically, November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table. Process and Outcome Indicators of
Resuscitation Care at the Individual, Family, and Medical Center Levels Individual Patient Level Process indicators Code personnel response as planned Equipment concerns Supplies available and adequate Process indicators specific to ventricular fibrillation or ventricular tachycardia Ventilation begun G1 min Compressions begun G3 min prior to 2011, G1 min 2011 and after Shocks initiated G3 min prior to 2011, G2 min 2011 and after Invasive airway established G5 min Epinephrine administered G5 min Process indicators specific to pulseless electrical activity or asystole Ventilation begun G1 min Compressions begun G1 min Invasive airway established G5 minutes Epinephrine administered G5 min Outcome indicators Survival postresuscitation Survival to hospital discharge
Family Level Process indicators Familyoffered option to be present and rationale noted if excluded from being present Family accepted offer Code stopped by family request Palliative care or organ transplant services as needed Family debriefing after witnessed resuscitation Outcome indicators Family_s response to witnessed resuscitation
Medical Center Level Process indicators Systems that support regular communication between clinical personnel and administrators Patterns of outstanding and less than outstanding implementation of procedures Use and sustainability of quality, evidence-based procedures Outcome indicators (totals by month and year) Resuscitations Ventricular fibrillation or ventricular tachycardia events Pulseless electrical activity or asystole events Events in intensive care units Automated external device utilization Survival postresuscitation Survival to hospital discharge Intubations described as difficult
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these data are used to generate graphs and benchmarking materials. A process was created to signal the Department of Quality and Patient Safety following pulseless events, to interview frontline staff to assess the series of patient events leading up to the pulseless event. Rich information is obtained from these interviews, resulting in numerous quality improvement projects. Frequently, further evaluation by the manager leads to policy/procedure revision as well as planned educational initiatives. Monthly, all pulseless events are reviewed by the manager and critical care medical director. Significant events are communicated to the Committee on Mortality and Morbidity for further exploration and comment. The communication link the manager provides among the varied councils, committees, and departments is crucial to the success of the resuscitation program. The planned structure allows for the ability to solicit feedback from as well as to communicate with and reinforce process changes to bedside nurses, multidisciplinary rapid response team (RRT) members, unit-based nurse educators, unit practice councils, Critical Care Performance Improvement Committee, and the Nursing Executive and the Quality and Safety Councils. The Critical Care Performance Improvement Committee, led by the manager and the critical care medical director, allows for high intensive care unit (ICU) staff nurse participation and important contributions to changes in patient careYrelated resuscitation practices. These meeting minutes are disseminated medical center-wide to administrators, clinical department directors, intensivists, and ICU staff nurses. The manager initiates and monitors the sustainability of several successful ongoing medical center-wide projects, such as the following: n Improving Handoffs Project. The manager implements and evaluates policies and action plans to coordinate handoffs of resuscitated, but yet comatose, patients who on admission to the emergency department undergo therapeutic hypothermia. These handoffs are often challenging because they are ongoing as the patient moves from the emergency department to computed tomography scan, the cardiac catheterization laboratory, the ST-segment elevation myocardial infarction unit, and/or the ICU. n Improving 911 Versus 555 (in Hospital) Emergency Call Project. The manager continuously refines the medical center’s comprehensive emergency management policy as it relates to resuscitation including the use of 555 (in house) versus 911 (community emergency medical services) for present and ever-expanding areas within medical centers including lobbies, new parking garages, and new wings containing a patchwork of rented and medical center-run physician offices. n Improving Recognition of Patient Deterioration Project. The manager coordinates the setting up of a system to place in each patient’s room a poster with a phone www.cns-journal.com
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FIGURE. Resuscitation process manager in a central role coordinating medical center-wide resuscitation care.
number for the family to call if they are concerned that their loved one is having difficulty. n Optimizing Resuscitation Equipment Use Project. The manager is in charge, medical center wide, of overseeing the procurement, location, storage, and appropriate use of all resuscitation-related devices and carts, including special difficult-to-intubate scopes, defibrillators, and capnography machines. The manager also disseminates information from webinars and industry representatives about use of this equipment. Specifically, the manager periodically evaluates the effectiveness of AEDs, tracks their use, problem solves, remedies any problems that arise with AED use, and revises evidencebased medical center policies about AEDs. Also at times the manager has been called upon to resolve, with a team, medical center-wide policy questions such as whether AEDs located in the medical center should be available for the use of staff only or for use by the general public in an emergency. Leadership Dimension 2: Use of Interprofessional Teams The manager effectively uses interprofessional teams to achieve identified improvement goals.4 The manager meets yearly in January with a respiratory therapist, physician assistant, physician, and nurse to discuss trends in resuscitation indicators from the previous year and subsequently meets with the Critical Care Performance Improvement team consisting of the chief ICU physician, other ICU physicians, staff nurses, and physical and respiratory therapists. They develop and initiate an action plan annually or any time 346
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there is an upward trend in the resuscitation data indicators. The manager then contacts administration about the need for equipment to carry out the action plan. For example, recently, data on the difficult-to-intubate resuscitation indicator led the medical center to buy more difficult intubation scopes. The manager updates policies, procedures, and protocols that govern the provision of CPR services and provides a mechanism for teaching and implementing high overall resuscitation quality, so that individual staff and teams function more effectively. Leadership Dimension 3: Integration of Evidence Into Practice The manager integrates evidence into practice to facilitate quality improvement .4 For example, the manager measures resuscitation outcomes and creates evidence-based forms (Rapid Response Team Form, Resuscitation Record) based on evidence-based AHA guidelines.2,5Y7 The critical roles and goals of the manager are in line with AHA standards of resuscitation care2,5Y7 in the areas of CPR-related devices, activation of RRTs, life support, family presence at resuscitation, and use of palliative care team and organ transplant services. The manager keeps up with changes in guidelines and in turn facilitates revisions to in-house protocols and procedures impacting resuscitation care such as medication sequencing and timing of defibrillation. The manager is a leader in evidence-based practice (EBP). The manager serves as a role model by publishing and presenting at conferences. He/she facilitates staff nurse attendance at EBP conferences and active participation during November/December 2014
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internet resuscitation webcasts. The manager collaborates with the medical center’s EBP Council to conduct EBP projects on resuscitation (such as understanding advantages of new types of equipment for the medical center). This manager also suggests how those interested in resuscitation can get involved with performance improvement or EBP or research projects to enhance resuscitation through shared governance nursing councils. Leadership Dimension 4: Staff Coaching to Develop Leadership The manager coaches staff to develop leadership at the bedside.4 He/she coaches the RRT nurses. The manager attends RRT meetings quarterly and encourages those nurses to talk about resuscitation and EBP-related resuscitation topics about processes or equipment used, such as capnography during a pulseless event. As the clinical leader during RRT calls, the RRT nurses must feel confident in their knowledge base and with their skills. The manager coaches the RRT staff as they monitor trends in the resuscitation indicators and implement action plans. To strengthen teambuilding skills, the manager may implement approaches used in advanced cardiac life support to facilitate leadership at the bedside. Nursing staff throughout the medical center are either directly or indirectly coached by the manager to recognize early signs of hemodynamic distress, call for the RRT, and begin to deliver competent emergency care to attempt to prevent further deterioration of the patient. Preparing and monitoring RRT for action, evaluating the quality of the response and the team’s perception of that quality, aiding intransition to computerized documentation for RRT care, monitoring processes and how well RRTs follow protocols, and facilitating team building are important roles for the manager alone or in conjunction with unit-based nurse educators. The manager might mentor staff on an evidence-based project on family-witnessed resuscitation. Through the development and completion of staff questionnaires, staff feelings on this topic can be explored that can lead to the creation of a successful protocol on family presence during a code situation. Evaluation items could include whether the family was given the option to be present, impression of the family’s response, debriefing of staff, and debriefing the family. Ongoing evaluation of this program can be accomplished with coaching from the manager. The manager may be called on to coach those writing policies about the initiation of palliative care and organ transplant. The timing of a palliative care specialist consultation and/or organ transplant services is important. Staff nurses and RRTs can be surveyed about their role in accessing these services, as well as approaches to provide the family with as positive an experience as possible. The manager also discusses case scenarios about the process of Clinical Nurse Specialist
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withdrawal of care, hospice options, and obtaining a donot-resuscitate order if that is the family’s choice. Although all palliative care situations related to resuscitation are stressful, some are more stressful than others. These situations require long-term follow-up support by the manager. As part of coaching, the manager invites staff to convey stories about situations in end-of-life care they have encountered as part of resuscitation. The manager coaches unit-based educators to become confident in running mock codes. These mock codes are conducted annually as part of yearly competencies using manikins or simulators and, depending on the requests, may be held as often as every 3 months. The shared governance unit practice councils may request mock codes be run at their meetings. Unit secretaries and physical and occupational therapists may request to be involved because they sometimes are present when the patient arrests, and they also want to know what to do in an emergency, how to get the crash cart, and what the terms mean. The manager recognizes that some nurses want to be mock code coordinators and unit champions for resuscitation; this enthusiasm can be rewarded if the medical center has a career ladder or similar system that recognizes outstanding leadership and initiative.
CONCLUSIONS Revisions to clinical guidelines for resuscitation care since the 1990s have resulted in medical centers developing improved resuscitation processes and outcomes that require management. The Institute of Medicine report, Health Professions Education: A Bridge to Quality,8 emphasizes leadership and recommends expanding opportunities for nurses to lead and diffuse collaborative improvement efforts, especially in collaborating to disseminate knowledge and create sustainable change. The resuscitation process manager role is very much in line with the institute’s recommendation. The manager has taken on a central role in coordinating the monitoring of a comprehensive list of evidence-based process and outcome quality indicators, utilizing interprofessional teams, integrating evidence into practice, and coaching staff. Outcome data on survival of event and survival to discharge at the Midwest medical center used as an example have suggested improvements over the years. In addition, bedside staff engagement in clinical resuscitation improvement initiatives, a core Magnet principle, is now common place. For example, in some locations, staff nurses have become so confident with initial responder basic life support priorities and responsibilities that they have assumed the coordination and delivery of mock codes. This demonstrates not only increased staff knowledge but also staff creating a work environment that supports excellence in nursing. Finally, various needs assessments continue to www.cns-journal.com
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Feature Article reflect the staff’s strong interest in mock codes and in the care of the deteriorating patient. Facilitating factors as well as barriers have been identified as they relate to implementing the manager role over time. Because of regulatory standards referencing improvement processes specific to emergency care, administrative and frontline management support continued to be strong. Ancillary department leaders and staff in multidisciplinary services at the medical center, including pharmacy and social work, had 1 point person to go to for all questions about resuscitation care. Collaborative relationships were easily established between the manager and many ancillary departments as a result of their work together on other critical care or patient-centered initiatives and projects. Recently, to benefit patient care, the decision was made collaboratively to purchase more difficult intubation equipment. Initiating any new role includes barriers of some kind. Three barriers are particularly noteworthy. First, a barrier was inconsistent management support from ancillary departments because of frequent changes in managers and staff as a result of organizational restructuring. Second, the implementation of a variety of projects simultaneously competed for the manager’s time and caused her to have to reset priorities often. Finally, the manager’s authority comes from expert knowledge, which does not include line authority, which presents some challenges with staff accountability. The manager worked at helping others to be part of the solution as problem situations in resuscitation care arose, as well as helping them be accountable for current standards of care. The major objective of the manager role is leadership in quality improvement. The framework by Finkelman4 is seen as appropriate to describe leadership aspects of this successful role at a medical center in the Midwest .The fact that the manager at the Midwest medical center was already a clinical nurse specialist meant that she already had autonomy to facilitate change and study the problem situations that emerged related to resuscitation care in order to find solutions; many situations are compelling and require immediate action or attention. By implementing this role
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using a clinical nurse specialist, hospitals are likely to experience a seamless process where the manager designs the ‘‘standard work’’ and possesses the ability to navigate among many different levels within the organizational structure. The clinical nurse specialist in this role uses a systems approach in his/her thinking to achieve the necessary goals. The clinical nurse specialist also has a clear understanding of the organizational pressures to deliver expert clinical care in the most efficient manner. Finally, he/she is well equipped to innovate and explore a multitude of options to deliver best practice resuscitation care. Designating a clinical nurse specialist in the resuscitation process manager role may be of interest to hospitals striving for excellence in evidencebased resuscitation care.
References 1. American Heart & Stroke Association. Top ten things to knowVCPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital. Published 2013. http://circ.ahajournals.org/ lookup/doi/10.1161/CIR.0b013e31829d8654. Accessed October 30, 2013. 2. Meaney PA, Bobrow BJ, Mancini ME, et al. CPR quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Published 2013. http://circ.ahajournals.org/content/early/2013/06/ 25/CIR.0b013e31829d8654. Accessed August 28, 2014. 3. Clements A, Curtis K. What is the impact of nursing roles in hospital patient resuscitation? Australas Emerg Nurs J. 2012;15:108Y115. 4. Finkelman A. The clinical nurse specialist: leadership in quality improvement. Clin Nurse Spec. 2013;January/February:31Y35. 5. Hazinski MF, Nolan JP, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Published 2010. http://circ.ahajournals.org/content/ 122/16_suppl_2/S250. Accessed October 30, 2013. 6. Becker LB, Aufderheide TP, Geocadin RG, et al. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association. Circ. 2011;124(19):2158Y2177. 7. Mancini ME, Soar J, Bhanji F, et al. Part 12: education, implementation, and teams: international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Published 2010. http://circ.ahajournals .org/content/122/16_suppl_2/S539. Accessed October 30, 2013. 8. Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington DC: The National Academies Press; 2003.
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