Provide one example, with supporting evidence, of an improvement in clinical practice as a result of clinical nurses' involvement in the implementation or evaluation of the professional practice model. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example One- An improvement in clinical practice as a result of clinical nurses' involvement in the implementation of the professional practice model.
Background Our Professional Practice model is the Synergy model of care. Synergy is based on the premise that the characteristics of the patient and the nurse unite to create a synergistic relationship that results in optimal patient outcomes.
In the Synergy model, each patient is unique and brings a set of characteristics to each health care situation. • Stability • Complexity • Vulnerability • Predictability • Resiliency • Participation in decision-making • Participation in care • Resource availability The nursing components of Synergy are: • Clinical judgment • Clinical Inquiry • Caring practices • Advocacy/moral agency • Facilitation of learning • Collaboration • Systems thinking Problem Patients with a diagnosis of stroke are at high risk of developing venous thrombosis. Evidence based care, as defined by the Centers for Medicare and Medicaid (CMS) Core measure, includes venous thrombosis prevention (VTE). There is no consistent practice at Thompson Hospital for the choice of VTE prophylaxis. Patients are either prescribed thromboembolic stockings or pneumatic compression devices. Goal To use clinical inquiry to bring the best evidence to the bedside for VTE prophylaxis. To improve compliance with VTE prophylaxis used for stroke patients by standardizing the approach to mechanical VTE prophylaxis. Intervention Literature review completed in February 2014.
Clinical Inquiry is defined as "The ongoing process of questioning and evaluating practice and providing informed practice; creating practice changes through research utilization and experiential learning". Jessica Schojan, RN, Charge Nurse, 3 West, having identified inconsistent practice in the management of VTE prophylaxis, embarked on a literature review to identify best practice to standardize the care for the patients on the stroke unit. The literature review focused on three randomized, controlled trials of modalities to prevent VTE. The first study identified the use of graduated compression stockings (CLOTS 1) did not change the risk of developing a proximal DVT, compared with no stockings. The second study (CLOTS 2) compared knee high compression stockings with thigh length compression stockings again showing no significant improvement in the risk of DVT with either device. There was a significant incidence of skin breakdown in the two studies using compression stockings. The final study in the series (CLOTS 3) published in 2013 did show an improved outcome with the use of intermittent pneumatic compression devices in patients with an acute stroke. The use of clinical inquiry at the expert level results in the evaluation of current practice based on patients' responses and review of the literature. At the expert level, the domains of Clinical Inquiry and Clinical Judgment converge. An expert nurse employing Clinical Judgment synthesizes data and makes judgment based on a grasp of the whole picture. As an expert nurse, Jessica utilized these two domains of Synergy to identify best practice in the prevention of proximal VTE in stroke patients. She developed a proposal to increase the availability of pneumatic compression devices to enable all patients with a diagnosis of stroke to receive this important prophylactic treatment.
Methodology
Trial Objectives
Participants
Results
CLOTS1
Randomized, outcome-based, multicenter controlled trials
Routine care + the use of thigh-high graduated compression stockings (GCS) compared to the use of no stockings
1,256 patients received thigh-high stockings while 1,262 received routine care
Thigh-high GCS were clinically ineffective and did pose risks. Skin breakdown occurred in 64 (5.1%) in group wearing GCS as opposed to 16 (1.3%) in those that did not wear them. Amputation occurred in 7 (0.6%) for GCS group and 2 (0.2%) for those without GCS.
CLOTS2
Routine care+ the use of thigh-high GCS compared to knee-high stockings
1,552 patients received thigh-high stockings, 1,562 received knee-high stockings
Acute immobilized stroke patients that wore below the knee stockings had a higher incidence of DVT than those that wore thigh-high however skin complications were more prevalent in those that wore thigh-high stockings. Skin breakdown occurred in 61 (3.9%)) for those that receive thigh-high GCS and 45 (2.9%) in those with knee-high GCS.
CLOTS3
Routine care +/- the use of intermittent pneumatic compression (IPC)
2,876 patients and enrolled patients from day 0 to day 3 of admission and via computerized system were allocated to either IPC or no IPC
The primary outcome (DVT in proximal veins) occurred in 122 (8.5%) of those patients allocated IPC and 174 (12.1%) of patients allocated no IPC with an absolute reduction in risk of 3.6%. Skin breaks occurred in 44 (3%) of those allocated IPC and 20 (1%) of those patients not allocated IPC. Falls with injury were reported in 33 (2%) of patients in the IPC group and 24 (2%) without IPC.
As a result of Jessica's proposal: • Education was provided to the clinical nursing staff working on 3 west (the designated stroke unit) in March of 2014 (Exhibit EP2EO.1). • Additional equipment was purchased to ensure that all stroke patients would receive the correct mechanical VTE prophylaxis in December of 2013. • Data was tracked to measure compliance with appropriate VTE prophylaxis. • Daily audit was performed to track compliance.
Exhibit EP2EO.1
Exhibit EP2EO.1 VTE Prophylaxis poster.pdf
Participants Jessica Schojan, RN, Charge Nurse, 3 West, Medical Surgical Unit, Department of Nursing Ragan Stevens, RN, SANE, Charge Nurse, 3 West, Medical Surgical Unit, Department of Nursing Amber Fulmer, BSN, RN, RN-BC, Charge Nurse, 3 West, Medical Surgical Unit, Department of Nursing Elizabeth C. Alexander, MS, RN, CN-E, Director of Medical-Surgical Nursing, Patient Care Services Sarah Gallagher, BSN, RN, CCRN, Quality Improvement Nurse, Stroke Center Coordinator, Quality, System Administration Susan McCormack, RN, Clinical Nurse, 3 West, Medical Surgical Unit, Department of Nursing Kathleen Hildebrandt, RN, Clinical Nurse, 3 West, Medical Surgical Unit, Department of Nursing Thomas Weibel, Director of Materials Management Data Requirements
Outcome(s)
The graph demonstrates an improvement in the use of Sequential Compression Devices (SCD's) for VTE prophylaxis. In June, 2014, compliance had reached 89%. Of the two patients that did not have SCD's for prophylaxis, one refused all VTE prophylaxis devices and the other patient expired soon after arriving on the floor.