2004 KNA Convention Research Poster Abstracts

2004 KNA Convention Research Poster Abstracts

Interventions to Control an Epidemic of Bloodstream Infections due to Mycobacterium chelonae and Mycobacterium fortuitum in Immunocompromised Patients

R. Carrico, L. Goss, K. Lloyd, Y. Nakatani, C. McDonald, and J. Ramirez,

Infection Control & Epidemiology Program,

University of Louisville Hospital,

Louisville, Kentucky

Rapid growing Mycobacterium species are commonly found in water environments. These bacteria are rarely associated with bloodstream infections. During February to June of 2002, an outbreak of bloodstream infections due to M. chelonae and M. fortuitum was documented at the University of Louisville Hospital. The objective of this study was to describe the outbreak investigation and the interventions implemented to control the epidemic. The following case definition was developed: isolation of M. chelonae or M. fortuitum from one or more blood cultures in a patient with a central venous catheter (CVC). Five patients met the case definition. All patients had underlying malignancies. None of the patients have evidence of local CVC site infection. Prior to development of infection, all patients had the CVC accessed for flushing. No common medications or caregivers were identified. Pulse-field gel electrophoresis identified as identical 3 of 4 M. fortuitum strains. All environmental cultures were repeatedly negative. Considering the characteristics of the outbreak, the following hypothesis was formulated: the etiology of the epidemic was likely related to the procedure for CVC flushing. Based on our hypothesis the following interventions were implemented: 1) do not open packages containing profiled saline syringes until immediately prior to use, and 2) do not remove the cap and put the needleless device on the syringe until immediately prior to use. The success of control measures was determined by monitoring for recurrence of infection. No additional cases of M. chelonae or M. fortuitum were identified in blood cultures after implementation of control measures. This study indicates that an epidemic of M. chelonae or M. fortuitum may result from intermittent, extrinsic contamination of sterile, preservative free intravenous flush solutions.

Continuous Lateral Rotation Therapy (CLRT): Knowledge Assessment of Critical Care Nurses

Mary June Cleaver, MSN, RN, Sara Robertson, MSN, RN, Cynthia McCurren, PhD, RN,

University of Louisville School of Nursing,

Louisville, Kentucky

Background. Prolonged immobility can cause many serious complications in the critically ill patient, including negative pulmonary effects, e.g. atelectasis, hypoxemia, pneumonia, and pulmonary embolism. CLRT was developed to decrease complications associated with prolonged immobilization. It is rotation therapy delivered on a table or cushion-based bed that slowly oscillates the patient. Investigators have reported that CLRT reduces the incidence of nosocomial pneumonia, hours intubated, and length of stay in ICU, thereby decreasing financial cost of medical care. Even though it appears that CLRT is beneficial to critically ill patients, the therapy is still used in only 54% of acute care hospitals nationwide. Furthermore, of the 54%, most use CLRT at random, without clear guidelines, and inappropriately in terms of initiation and sustained clinical application. Reports from numerous clinical experts suggest that a contributing variable to these nonuse/misuse issues, is a knowledge deficit among critical care nurses regarding CLRT.

Purpose. The purpose of this study was to assess knowledge among critical care nurses regarding CLRT, in order to develop continuing education initiatives to address specific learning needs and ultimately promote the development of CLRT clinical protocols. The belief was that improving knowledge about the physiological alterations associated with prolonged immobility, and CLRT as an intervention, would increase the appropriate and correct use of CLRT, eventually improving patient outcomes.

Method. For this descriptive study, a 20-item CLRT knowledge questionnaire was distributed in staff meetings to 110 critical care nurses from two large acute care hospitals. The questionnaire was made up of multiple-choice items testing pulmonary physiology, basics of CLRT, and physiological parameters for determining when to begin and terminate CLRT. Since no instrument measuring CLRT knowledge existed, the questionnaire was developed for this study, derived from the literature and examined for content validity by two nurse experts. The score ranged from 0-20, and a score of

Results. Forty-one of the 110 questionnaires distributed were completed, for a return rate of 37.3%.

* 26 of the 41 (63.4%) had previously observed CLRT in their practice

* 10 of the 41 (24.4%) reported feeling completely knowledgeable about the application and use of CLRT

* There were no significant differences in CLRT Knowledge Questionnaire score analyzed by age, education, years in nursing, or years in current ICU position.

All 41 critical care nurses participating in this study demonstrated a knowledge deficit with regards to CLRT (score of

Conclusions. On the basis of this assessment, appropriately focused educational initiatives should be identified. The overall low scores suggest a comprehensive education program should be developed regarding all aspects of CLRT utilization. Such a program has the potential for wide-spread use, ultimately improving outcomes of patients with prolonged immobility and alterations in pulmonary function.

Work Intensity Project

Robbie Eastham, RN and Gayla Edin, RN

Lebanon, Kentucky

The literature abounds with issues regarding the nursing shortage and the environment in which nurses work. One of the major issues cited is the intensity of work that nurses manage. Since the intensity of work impacts whether the nurse plans to stay in the job or in nursing, it is an issue that all employers of nurses need to evaluate and mitigate, if possible. Through a multihospital focus group comprised of nurses with direct care responsibilities issues impacting work intensity and strategies to diminish work intensity were identified. Over one year the solutions were developed into projects at various facilities and expected outcomes were documented. Six months after implementation of the projects outcome data was reported. It was hoped that projects that were implemented at one or two facilities could be measured for effectiveness and provided as a guide for other facilities to implement. The projects included: Isolation Protocol, Enhanced use of LPNs, Satellite Nursing stations and Terminals, Unit Based Educators, Centralization of Equipment Support, Care Maps LOS, Shift Division of High Intensity Tasks; Reevaluation of metrics for accuracy and analysis, Revision of charge nurse role, Shared Governance Model development, Communication Devices, Outpatient Care Area, ADT nurse. This presentation outlines the initial process in identifying and developing these projects. Results of the various projects included increases in patient or nurse satisfaction, standardization of metric information, development of staff empowerment, and others.

Online Education to Support Caregivers of Persons with Dementia

Karen M. Robinson, DNS, APRN, BC, FAAN and David Shelton, BSN, RN

University of Louisville School of Nursing

Louisville, KY

Telehealth, online technology to deliver caregiver support interventions, offers a cost effective alternative to home visits. The purpose of this project was to put the caregivers’ training online. Following enrollment, telehealth methods were used to transition the current Volunteer Caregivers Program training book modules into an electronic form available via any internet connection. Limitations included: users without computer experience, user sensory limitations, needs for data tracking and restraints of the Blackboard Learning System as the program proxy. On completion of the transition from professionally presented training to online training, a pilot study evaluated the concept, format, accessibility, and presentation of training. The pilot study enrolled 28 students/staff/associates affiliated with the program. The initial study sample, however, only included six subjects, all female, who directly or indirectly care for family members with dementia. Descriptive statistics were used to assess the caregiver’s level of knowledge, pre-training and post-training. All subjects demonstrated higher knowledge post training. Qualitative questions were used to determine level of accessibility, convenience, and usefulness to caregivers.

A Dose Will Do You: A Computerized Approach to Evaluating the Use of Antimicrobials and Promoting Patient Safety in the Acute Care Setting

Linda K. Gross, BS, RN, C, CIC

Infection Control Nurse and Informatics Specialist

University of Louisville Healthcare

Louisville, Kentucky

Antimicrobial teams are commonly used in health care facilities to track the use of antimicrobials and improve the process. Software was developed at the University of Louisville Hospital for use with a personal digital assistant (PDA). The program is used to aid in antimicrobial evaluation and generate customized feedback for analysis. The S.T.A.R.© (Switch Therapy and Antibiotic Review) program works in conjunction with a relational database created using Pendragon Forms 3.1 (Pendragon Software Corporation, Libertyville, IL).

Effectiveness and Cost Savings of Interventions to Control a Hospital Outbreak of Clostridium difficile Colitis.

P. Schulz, R. Carrico, L. GOSS, K. Lloyd, Y. Nakatani, C. McDonald, and J. Ramirez

Infection Control and Epidemiology Program

University of Louisville Hospital

Louisville, Kentucky

Centers for Disease Control and Prevention

Atlanta, Georgia

Clostridium difficile colitis (CDC) outbreaks cause significant increases in patient morbidity and hospital costs. A recent study estimated the hospital cost of one case of CDC to be $3669. Between October 2001 and September 2002 the University of Louisville Hospital experienced an outbreak of CDC. The objectives of this study were to describe the interventions used to control this outbreak and the associated cost savings. A case of CDC was identified when stool from a symptomatic patient hospitalized at least 48 hours tested positive using an enzyme immunoassay for the detection of C. difficile toxin A and B. The investigation to determine the causes of the outbreak focused on changes in antibiotic usage, barrier precautions (e.g. glove use and hand washing), and environmental factors (e.g. room disinfection and equipment used during procedures). The interventions implemented as a result of our investigation were: 1) feedback to the surgery and medicine services informing them of the outbreak, encouraging hand washing with an emphasis on alcohol gel use, and reviewing isolation procedures, 2) retraining environmental cleaning services, 3) changing from a quaternary ammonium to a phenolic cleaning agent, and 4) replacing rectal thermometers used by an entire unit with individual disposable rectal thermometers. Prior to the outbreak we identified an average of 11 cases of CDC per month per 1000 admissions. During the outbreak this average increased to 24 cases of CDC per 1000 admissions. The interventions described above resulted in a current average of 9 cases of CDC per month per 1000 admissions. This represents an estimated annual reduction in the total number of CDC cases of 180 per year and an associated annual hospital cost savings of $660,420. This study indicates that an active infection control and epidemiology program can control C. difficile outbreaks reducing patient morbidity and hospital costs.

Empowerment of Rural Elders in the Use of the Health Care System

M. Susan Jones, PhD, RN

Marilyn Gardner, PhD

Jan Peeler, MSW

Western Kentucky University

Bowling Green, Kentucky

Health Enhancement of the Rural Elderly (HERE) Is a three-year project designed to maximize the effective use of the health care system among the rural elderly. A major initiative of the project was to develop, implement, and evaluate educational modules that enhance patient-provider communication through improved health literacy and communication skills. The presentation will provide an overview of the process by which this multi-component intervention was developed using an interdisciplinary team of faculty and students from nursing, public health education, and social work, in conjunction with an expert panel of community practitioners. Also presented will be the findings from the first year of implementation in a medically underserved rural community in the mid-south: A quasi-experimental pre-post design was used to test the effectiveness of the modules. Lessons learned and future directions for the final year of the project will be discussed as well.

Clinical Decision Beds

Robbie Eastham, RN and Gayla Edin, RN

Spring View Hospital, Lebanon, Kentucky

The need for increased cost containment and maximization of equipment, personnel and space usage continues to plague the field of nursing. We as professional nurses need to be ever diligent in our practice. The need to always be alert to the ever changing world around us and in our hospitals has never been so great as it is now, so we must best utilize what we have in a more efficient and cost effective manor while maintaining the highest quality of care that is possible and meet the needs of our nurses, physicians and most importantly our patients. We, as health care providers, must be innovative and compassionate at the same time. Spring View Hospital, in 2002, realized that there were problems occurring in the Emergency Department that focused on patients that complained with chest pain. They were either being held in ED for repeat enzymes, placed in 23 hour observation, admitted to ICU, Med/Surg or Telemetry Unit. The Emergency Department volumes were skyrocketing resulting In stressing the current practice of holding them for observation. The Primary Care Physicians were evaluating chest pain following inpatient placement only to decide to discharge them home. Upon evaluation which increased their workload, ICU staff was being transferred to other units or placed on call due to low census. The ED was not receiving reimbursement from Medicare for patients that were being observed In the ED. There were a couple of negative outcomes with patients that were held in the ED then home disposition was the outcome. ICU staffs, Physicians and Patients were also being negatively impacted. The processes were reworked in their entirety and the seven step PI process was implemented. Buy-in was obtained from the involved departments and medical staff. Guideline for chest pain observation was obtained from the American College of Emergency Physicians packet of General Observation Information. Through a team approach input was solicited from System Cardiovascular Services representative. The necessary policies and procedure were created and staff was educated to the change in process before implementation. The hospital implemented the Clinical Decision Beds for chest pain candidates on 02/06/03. Through monitoring of patient outcomes and satisfaction surveys we at Spring View Hospital feel that this process was developed by using modern nursing critical thinking and best practice utilization.

Reducing Farmers’ Risk for Hearing Loss Part I

M. Susan Jones, PhD, RN,

Western Kentucky University

Donna Gates, EdD, RN, University of Cincinnati

Emmanuel lyiegbuniwe, PhD,

Western Kentucky University

Bowling Green, Kentucky

Farmers experience a high prevalence of hearing loss due to occupational noise exposure along with toxic chemical exposure, age, and recreational noise exposure. Although noise induced using hearing protection devices can prevent hearing loss, most farmers and their family members do not wear them enough to protect their hearing. The purpose of this pilot study was to test the effectiveness of an intervention to increase farm workers’ use of hearing protection when performing activities with high noise exposure. The proposed intervention applied concepts common to the field of behavioral theory. Like many busy people today farm workers are more likely to wear hearing protection if the behavior is perceived to have significance to their lives, if it is readily available, when they are reminded to use the protection, and when they are encouraged to do so by their loved ones. The sample included members of the Farm Bureau Association in two south central Kentucky counties with farmers from one county serving as the intervention group (N=8) and farmers from the other county as the comparison group (N= 19). The instrument used was developed by the investigators and included a questionnaire to elicit demographic information, occupational and hearing histories, and frequency of hearing protection use along with a survey containing 14 statements on a 5 point Likert scale developed to measure the concepts theorized to influence the frequency of hearing protection. Data were collected from both the comparison and intervention groups at two-month intervals during the 6-month study. Following the initial data collection, the intervention group received a short presentation about noise induced hearing loss, farm visits to conduct noise assessments, return visits to the farms to place hearing protection at strategic sites, and brochures on the benefits of hearing protection use. Findings indicate that 88% of the farmers never or seldom wear hearing protection and 64% of the farmers report they know someone with a hearing problem related to farming. Preliminary findings suggest the interventions were effective in increasing hearing protection use among the farmers.

A Nursing Perspective of An Evidence Based Model for Acute Psychiatric Treatment

Peter W. Hess, IV, RN, MHA; Scott Hutton, RN, MSN; Carol H. Rumpler, MS, APRN, BC, and all members of the 7 North Inpatient Unit,

Cincinnati V.A.M.C., Cincinnati, Ohio

A multidisciplinary mental health treatment program was implemented to address the question of how to measure the therapeutic effectiveness of treatment on an acute psychiatric unit. Per the literature, theoretic efficacy has been measured by diagnosis, previous hospitalization, demographic variables, symptomatology, level of functioning, changes to quality of life, patient satisfaction, access to resources and medication compliance. Through the use of five instruments, patients admitted to the acute psychiatric unit were measured on five markers, including Global Assessment of Functioning (GAF) (staff-rated), Symptom Discomfort Scale (SDS) (patient-rated), Patient Satisfaction Survey (PSS) (patient-rated), Medication Education Questionnaire (MEQ) (patient-rated) and Veterans Resource Book (VRB) (staff-evaluated and patient written), for treatment efficacy.

The core of the treatment program is the VRB which the patient completes as she/he proceeds through treatment. Mentoring patients through a primary nurse, community meetings, medication education, discharge planning, dedicated time for writing in the VRB, after care and a partial program keep patients involved in the treatment model.

After the program, the results showed a high positive correlation between patient satisfaction and quality (r=.82 p

An Analysis of Factors Contributing to Nurses’ Dissatisfaction with Employment and Recommendations for Modifying the Work Environment

Kathy Hager, Kathy Morris, Leandra Price

Doctorate of Nursing Practice Students

University of Kentucky

This poster presentation addresses the issue of nurses’ vulnerability, their reasons for loving nursing, their reasons for leaving nursing, and their reasons for staying. It provides a theoretical framework based upon a transactional model of coping, in which stressful experience that may be perceived as positive or negative, is perceived as positive. It then offers an evidence-based model that sets the stage for nurses to ‘stay.’

In much of the research, it is suggested that leadership in nursing plays a large role in the nurse leaving or staying.’ Transformational leadership is a method of nursing leadership, in which the leader involves the nurse at every level in decision-making, instills faith, transmits a sense of mission, communicates a vision, and establishes an environment conducive to the nurse being able to nurse. This type of leadership has been identified as one that allows nurses to feel ’empowered’ and want to stay in the profession.

The research suggests that activities must be undertaken to ensure that leaders can lead effectively, provide autonomy for the nurse, and establish an environment that allows the nurses to take care of patients. Furthermore, the research suggests that the employer should provide and encourage the use of wellness centers, and that the educators must identify a method for teaching resiliency to the nursing student. Resiliency in the nurse has been identified in the research as a trait that translates into nurse retention.

The Planetree Model is explored as just one example of transformational leadership in action. The nurse leader using this model has the highest staff satisfaction in all five of the partner hospitals.

Copyright Kentucky Nurses Association Jan-Mar 2005

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