Volume 9│Issue 2│June 2018 Carilion Medical Center, 1906 Belleview Ave, Roanoke, VA 24014 http://chsweb.carilion.com/nursserv/NursW eb.html nursingresearch@carilionclinic.org (540)266 -6216
Discovering the difference: QA/QI, Research & Evidence Based Practice Deirdre Rea, MSN, RN, PMH-BC - Carilion Connect Director & Member, Within REACH Editorial Board Quality Improvement (QI), Evidence-Based Practice (EBP) and Research are terms often heard in healthcare today. While they may seem interchangeable, each is a distinct type of project with distinct frameworks and methodologies to guide the work. Quality improvement is done when there is enough evidence already available to have developed a standard. QI looks to close the gap between the standard that has been established and the actual performance. For example, research shows that, for patients with chest pain, a short ‘door-to-EKG’ time improves patient outcomes. A QI project might look at measuring that time frame in your area and developing an intervention to reduce a time delay. Methodologies might include Lean Six Sigma or the Plan Do Study Act (PDSA) framework. When a problem is found for which there is very little evidence, or the evidence is equivocal, nursing research is conducted. Research can be used to explore a little known phenomenon, in which case one might conduct qualitative research with interviews or observations. An example might be the exploration of staff attitudes toward high-utilizing patients or an observation of patient receptivity and behavior during discharge teaching. Research is also used to test a hypothesis about the relationship between specific variables. A quantitative study could determine both the presence and the strength of that relationship. This might involve an experimental design of an intervention with a pre-test and post-test measurement to look for degree of association, correlation or change. Evidence-Based Practice falls in the middle. With EBP, there is enough evidence to guide practice, but it has not been well established or widely adopted enough to be made a standard. The aim of EBP is to take the findings from nursing research and translate them into your everyday practice. This starts with a PICOT question followed by an extensive review of the literature to find and evaluate the strength of the available evidence. If the evidence is sufficient, it can be used to develop and test a practice change. For example, after a thorough review of the literature indicating strong evidence, the next ste[ pf EBP is to identify a protocol for assessing agitation and violence, implement the protocol, and assess data on the effectiveness of the protocol. It is in the area of EBP that we can make the biggest difference for our patients and our practice. I challenge you all this year to find a PICOT question to explore! References Baker, K., Clark, P., Henderson,D., Wolf, L., Carman, M….Zavotsky, K. (2014). Identifying the differences between quality improvement, evidence-based practice, and original research. Journal of Emergency Nursing, 40(2),195-197. Ogrinc, G., Nelson, W., Adams, S., O’Hara, A. (2013). An instrument to differentiate between clinical research and quality improvement. IRB: Ethics and Human Research, 35(5), 1-8.
Carilion Clinic Roanoke Campus
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ARTICLES & DEPARTMENT INFO 1 Discovering the difference: QA/QI Research & Evidence Based Practice Deirdre Rea, MSN, RN, PMH-BC
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2018 Nursing Research Conference - Save the Date & Call for Abstracts Determining postoperative outcomes in vascular surgery patients who received non-autologous implants with and without intraoperative surgical site antibiotics (ISSA) Cheryl Bennett, MSN, RN, CNOR; Karen Kline, RN, CNOR; James Drougas, MD; Cathy Jennings, DNP, RN, ACNS-BC
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Korean Nursing Students from Roanoke’s Sister City Visit CRMH Cathy Jennings, DNP, RN, ACNS-BC; Ellen Harvey, DNP, RN, ACNS-BC, CCRN, TCRN, FCCM
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Characteristics and outcomes of heart failure patietns who participate in cardiac rehab. Renee Gerow, MSN, RN; Nancy Altice, DNP, RN, CCNS, ACNS-BC
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Little teeth, big problem: Pediatric toothbrushing and hospital acquired pneumonia Katherine Lilley, BSN, RN; Allison Walker, BSN, RN, CPN; Donna Bond, DNP, RN, CCNS, AE-C, CTTS; Ava Porter, DNP, RN, CNE
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Dispelling palliative care myths Johnathan Phillips, MSN, MSEd, RN-BC
RECOGNITION/EVENTS 12 2018 Week of the Nurse Art & Science of Nursing Showcase Highlights 14 2018 Week of the Nurse Art & Science of Nursing Showcase Summary 16 2018 Week of the Nurse Art & Science of Nursing Showcase Poster Winners 18 2018-19 Nursing Research Fellows 19 2017 Nursing Research Fellows Graduation 20 Nursing Recognition 22 Conference Corner 24 Citations & Recognitions 26 “See Where Our Nurses Have Presented” Map 27 Welcome Summer Interns 28 Nursing Research Classes
Within REACH Editorial Board: Kimberly Carter, PhD, RN, Editor Margaret Perry, MSN, RN, Associate Editor Candace Asbury, BSN, RN Sarah Browning, DNP, RN Monica Coles, MSN, RN-BC, ACNS-BC Donna Goyer BS, RN, CPAN, CAPA Christine Huson, MSN, RN James Ingrassia, MSN, RN Michele Kosinski, DNP, MBA, RN Deirdre O. Rea, MSN, RN Angelina Surgent, MSN, RN, ONC Cindy Ward, DNP, RN-BC, CMSRN, ACNSBC Vivian Wilson, BSN, RN, CCRP Beth Assenat, BS
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To submit your abstract, go to: http://insidecarilion.org/webform/abstract-submission-0
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Determining postoperative outcomes in vascular surgery patients who received nonautologous implants with and without intraoperative surgical site antibiotics (ISSA) Cheryl Bennett, MSN, RN, CNOR1; Karen Kline, RN, CNOR1 James Drougas, MD2; Cathy Jennings, DNP, RN, ACNS-BC2 (mentor) - 2017 Carilion Nursing Research Fellowship 1. CRMH Vascular OR; 2. Vascular Administration Background Surgical site infections (SSI) account for approximately one-fifth of all hospital acquired infections (HAI)1. For the postoperative patient, an SSI can have significant personal, functional, and financial impacts 1,2. Although the use of perioperative intravenous antibiotics is a key strategy in the prevention of SSI, ISSA use is described much less in the current research literature. Current ISSA practice in vascular surgery patients at the study site is by surgeon preference. Objective The purpose of this retrospective data review was to determine the incidence of 3 postoperative outcomes: surgical site infection (SSI; defined as an infection within 30 days postoperatively), surgical wound variance (SWV, defined as a wound “other than normal or as expected”), and all-cause readmission rate (RR; occurring within 30 days of hospital discharge) in vascular surgical patients who receive non-autologous implants with ISSA and those who did not. Method This IRB approved research study included a convenience sample of surgical encounters from one surgical provider group, composed of a total of 456 surgical encounters when non-autologous implants were used: 248 with ISSA and 195 without ISSA, in calendar years 2013-2014. Encounter patients had a mean age of 69 years, were predominantly male (60%), and had a mean ASA score of 3. Descriptive and demographic data were abstracted from 2 sources for each surgical encounter: (1) the hospital electronic medical record (EMR), and (2) from the provider office EMR (postdischarge follow-up). The data were then compared for differences between the groups in 3 outcomes: incidence of SSI and SWV 30 days postoperatively and all-cause RR 30 days post-hospital discharge. Results No statistically significant differences in surgical site infection between the ISSA and no-ISSA encounter groups were identified, although more surgical encounters in which ISSA was used included an SSI (12[4.84%] versus 5[2.56%]; p=0.216). Similar findings were seen with SWV: no difference between groups was found, although more surgical encounters in which ISSA was used included a SWV (35 [14.11%] versus 21[10.77%]; (p=0.2931) ). A difference was found, however, between the groups in all-cause readmission rates (p=0.0282). A total of 34 surgical encounters (13.71%) in which ISSA was used included a readmission for any cause, whereas 14 encounters (7.18%) without use of ISSA included a readmission. Surgical encounters with ISSA resulted in longer hospital lengths of stay (1.3 more days, p=0.0382), fewer discharges to home with self-care (77% versus 84.6%), more use of home health services (13.31% versus 7.18%) and slightly more discharges to a rehab/other care facility (8.87% versus 8.21%). Discussion Although not statistically significant, it is clinically significant that more SSI’s occurred in encounters in which ISSA was used, and more SWVs occurred in encounters in which ISSA was used. More all-cause readmissions occurred in ISSA encounters (p=0.0282). In addition, encounters that included ISSA more often required longer lengths of stay (p=0.0382), and more often required home health services or higher level of care post-discharge. Nursing Implications This study suggests relevant Nursing implications in the preparation and use of intraoperative surgical site antibiotics in this patient population. The Registered Nurse (RN) is a patient advocate and primary team member in the Operating Room. The RN should encourage discussion among surgical team members regarding appropriate uses of ISSA for each individual patient. Findings support the recommendation that the RN not routinely prepare and place ISSA on the surgical field without a team discussion and physician order. Additional factors of ISSA cost to the patient and increased potential for antibiotic resistance should also be considered. References 1. 2.
McHugh, SM (2011). The role of topical antibiotics used as prophylaxis in surgical site infection prevention. Journal of Antimicrobial Therapy, 6, 693-701. Barnes S, Spencer M, Graham D, & Johnson HB. (2014). Surgical wound irrigation: A call for evidence-based standardization of practice. AJIC: American Journal of Infection Control, 42:5, 525-529.
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Korean Nursing Students from Roanoke’s Sister City Visit CRMH! Cathy Jennings, DNP, RN, ACNS-BC1; Ellen Harvey, DNP, RN, ACNS-BC, CCRN, TCRN, FCCM2 - 1. Vacular Administration; 2. CRMH 9M NTICU While much of the world was focused on the Winter Olympics at PyeongChang, South Korea, four Korean Nursing students were visiting the Star City and Carilion Roanoke Memorial Hospital (CRMH). At the invitation of Eunyoung Lee PhD, RN, FNP, ANP, ACNP, FAHA, Associate Professor and Coordinator of the Korean/Taiwan Study Abroad Program at Radford University School of Nursing (RUSON), a team of Carilion nurses had the pleasure of hosting four South Korean Nursing students at CRMH on February 6, 2018. The students, from Yonsei University’s Wonju campus, are the second such group to participate in a highly selective two-week study program offered by RUSON1. Virginia Tech Carilion School of Medicine also participates in a student exchange program with Yonsei1. Coincidentally, the South Korean city of Wonju – more than 7,000 miles from Roanoke – has been one of Roanoke’s seven sister cities for over 50 years1. For this exciting opportunity, Ellen Harvey DNP, RN, ACNS-BC, CCRN, TCRN, FCCM, Kris Peters MSN, RN, Charles Bullins II, MSN, AGACNP-BC, and Cathy Jennings DNP, RN, ACNS-BC represented CRMH as student hosts. Kris and Ellen provided an “up close and personal” tour of the Emergency Department and Trauma Bays, along with a review of the structure of trauma care in the United States and the top-level trauma care provided at CRMH. Additionally, the group discussed in roundtable format the US health care delivery system and the many services and programs provided at CRMH. Advanced practice nursing roles in the US were explored, and two advanced practice nurse roles which are currently in place and vibrant at CRMH were reviewed: Clinical Nurse Specialist (CNS) and Acute Care Nurse Practitioner (ACNP), including the educational preparation, key role components, clinical areas, and scope of practice for each. Both students and hosts were fully engaged in this lively and informative session, which was later described in a news report on Roanoke’s WSLS 101. The experience was an enriching opportunity for Carilion Clinic nurses and students alike to partner on a global level in support of the communities we serve. Reference 1. McGraw, B. (2018). Roanoke celebrates South Korean sister cities connection. WSLS 10 News Live Interview and Article. Retrieved on March 1, 2018 from https://www.wsls.com/news/virginia/roanoke/roanoke-celebrates-southkorean-sister-cities-connection
Front row: Dr. Eunyoung Lee and students from Yonsei University Wonju Campus. 2nd row: Dr. Cathy Jennings, Dr. Ellen Harvey, Charls Bullins II.
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Characteristics and outcomes of heart failure patients who participate in cardiac rehab. Renee Gerow, MSN, RN 1; Nancy Altice, DNP, RN, CCNS, ACNS-BC2 (mentor) - Carilion 2017 Nursing Research Fellowship 1. Carilion New River Valley Medical Center/Cardiac Rehab; 2. CRMH Cardiology Services Background: The Centers for Medicare and Medicaid Services (CMS) initiated Cardiac Rehab (CR) coverage for heart failure (HF) patients in 20141. Current guidelines stipulate that these patients have an ejection fraction of 35% or less with NYHA class II to IV symptoms. The patient also must be considered stable, having been discharged from the hospital at least six weeks prior to starting rehab, and have no planned hospital admissions for the next six months2. Unfortunately, the new CMS guidelines leave a gap in service. Patients with a preserved ejection fraction (HFpEF) are ineligible for coverage through Medicare. Since HPpEF is the most common form of heart failure in the older population, with incidence doubling each decade following the age of 65 years, many of these patients remain untreated3. Medicare has reduced hospital reimbursement for patients readmitted within 30 days following discharge. The 60 day readmission rate for these patients is 20 -25% in the United States2. Bergathon, et al. (2016) reviewed data from the Get With The Guidelines Heart Failure Registry and found that 30 day readmission rates improved a mere 1% during the years from 2009 to 2012 - 20% to 19%4. High 30 and 60 day readmission rates for this patient population suggests that the current six week waiting period for Medicare-covered HF patients may not be best practice, and that an earlier timeframe for starting CR may lead to better outcomes. Carilion Clinic, a not-forprofit, integrated healthcare organization located in Virginia, has attempted to bridge this gap in service by providing an 8 session free CR program. This program has been in existence for more than 10 years, and is accessible to all patients with a HF diagnosis. The aim of the 8 session free CR program for HF patients is to improve the health of this population and reduce readmissions. By providing monitored exercise sessions, education, and reinforcement of learned materials, patients are encouraged to become knowledgeable and responsible partners in their own healthcare. The 8-session program, which consists of rehab sessions twice weekly for one month, allows for early identification and intervention when problems present. Purpose The focus of the study was to determine if starting CR prior to six weeks post discharge from the hospital reduced readmission rates. Method This IRB-approved study used a retrospective quasi-experimental comparison group design incorporating Epic Electronic Medical Record analysis for HF patients discharged between March 2013 and December 2017. Early CR attendance (within six weeks of discharge from the hospital) and readmission rates were evaluated in this study. HF patients who attended CR monitored, maintenance, and the free 8 session program were included. Certain patient characteristics were also evaluated for their impact on re-hospitalizations. The treatment group was identified as HF patients who had attended at least one CR visit within the first 6 weeks following discharge. The comparison group was identified as all HF patients who had not been admitted to the hospital during the previous one year period, were discharged to home/self-care, and did not attend CR within six weeks of being discharged from the hospital. Thirty-day and 6-week readmission rates were compared between the treatment and comparison groups. Findings Out of 8,613 HF patients, 205 (2.4%) attended at least one session of CR within six weeks post discharge. Readmission rates for comparison group versus treatment group were: 2.7% versus 1.0% for 30-day readmission for HF (p=0.13); 14% versus 5.9% for 30-day all-cause readmission (p<0.01); 3.5% versus 1.0% for 6-week readmission for HF (p<0.05); 17% versus 7.7% for 6-week all-cause readmission (p<0.01). Multivariable Logistic Regression revealed that early CR attendance was associated with reduced 30-day all-cause and 6-week all-cause readmissions when adjusted for age, diagnosis of pulmonary disease, dialysis treatment, and Medicare insurance which were associated with increased readmission.
Impact on Nursing Statistically significant study results support early access to CR in reducing re-hospitalization rates. Study limitations include unbalanced sample sizes which increased variance and lowered statistical power, potential bias due to exclusion of mortality outcomes, and operationalization of CR as attendance to only one session. Current CMS criteria does not permit early access to CR and limits enrollment to a specific sub-group of this patient population. Future studies are needed with designs that further explore the impact of CR on HF readmissions. Nurses who care for heart failure patients should consider recommending CR as a beneficial intervention. References 1. Aspry, K., Wu, W., & Salmoirago-Blotcher, E. (2016). Cardiac rehabilitation in patients with established atherosclerotic vascular disease: New directions in the era of value-based healthcare. Springer Science+Business Media New York, 1-7. 2. Soundarrai, D., Singh, V., Satija, V., & Thacker, R. (2017). Containing the cost of heart failure management Heart Filure Clinics 13(1), 21-28 3. Schopfer, D.W., & Forman, D. E. (2016). Growing relevance of cardiac rehabilitation for an older population with heart failure. Journal of Cardiac Failure, 22(12), 1015-1022. 4. Bergethon, K. E., Ju, C., Devore, A.D., Hardy, C., Fonarow, G.C., & Yancy, C.W., et al. (2016). Trends in 30-day readmission rates for patients hospitalized with heart failure: Findings from get with the guidelines heart failure registry. Circ Heart Failure, 1-8. DOI: 10.1007/s11883-016-0561-x.
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Little teeth, big problem: Pediatric toothbrushing and hospital acquired pneumonia Katherine Lilley, BSN, RN1 ;Allison Walker, BSN, RN, CPN1, Donna Bond, DNP, RN, CCNS, AE-C, CTTS2 (mentor), Ava Porter, DNP, RN, CNE3 (mentor) - 2017 Carilion Nursing Research 1. CRMH 11S Pediatric ICU; 2. CRMH Pulmonary; 3. Jefferson College of Health Sciences Background Hospital acquired pneumonia (HAP), including ventilator acquired pneumonia (VAP) and postoperative pneumonia (POP), contributes to increased length of stay, readmission, increased ventilator time, healthcare costs, and presumably decreased patient/family satisfaction1,2,3 . This substantiates a need for higher level of awareness and proactive prevention by healthcare providers. In adult populations, oral care bundles have proven effective in preventing HAP, and poor oral health has been associated with HAP in elderly and institutionalized populations3,4,5,6,7,8 . Preoperative toothbrushing has been shown to be effective in reducing postoperative pneumonia in the adult population4,10,11 . Minimal research exists in the pediatric population concerning HAP, with the exception of some studies performed on oral care bundles for VAP. Purpose Prevention of HAP, VAP and POP in the pediatric population through pre-procedural or pre-operative tooth brushing is what is investigated in this project. Method This project used a retrospective pre and post intervention design to determine the incidence of HAP and the effect of preoperative and preprocedural toothbrushing compared to those patients who did not have the intervention on the incidence of HAP in surgical and procedural pediatric patients admitted to Carilion Roanoke Memorial Hospital. Given the data and population available, 100% of patients that fit criteria were used in study, therefore a power analysis was not warranted. Total sample size for study was 2637 patients (1312 pre/1325 post). In the postintervention group, 625 patients were documented to receive intervention of toothbrushing, identifying a problem with documentation. Descriptive statistical analysis was conducted on both pre- and postintervention groups and chart reviews were performed on patients diagnosed with pneumonia. The preintervention group had 4 pneumonia diagnoses and the postintervention group resulted in 3 pneumonia diagnoses. In the preintervention group, 3 pneumonias were present on admission. In postintervention group, 2 were discovered to be present on admission after chart review. Findings The incidence of HAP in pediatrics is low. The average time between toothbrushing and procedure time was 1.5 hours, with the goal being under 1 hour at the start of the study. The intervention did not prove to be statistically significant in rate of HAP. A larger study with closer monitoring of documentation is potentially warranted to further evaluate the intervention. Implications for nursing are emphasis on daily care and emphasis on documenting interventions performed throughout the day.
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References 1.
Davis, J., & Finley, E. (2012). The breadth of hospital-acquired pneumonia: Non-ventilated versus ventilated patients in Pennsylvania. Pennsylvania Patient Safety Advisory, 9(3), 99–105.
2.
Esperatti, M., Ferrer, M., Theessen, A., Liapikou, A., Valencia, M., Saucedo, L. M., Torres, A. (2010). Nosocomial pneumonia in the intensive care acquired by mechanically ventilated versus nonventilated patients. American Journal of Respiratory Critical Care Medicine, 182, 1533–1539.
3.
Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic Nursing Care to Prevent Nonventilator Hospital-Acquired Pneumonia. Journal Of Nursing Scholarship, 46(1), 11-19. doi:10.1111/jnu.12050
4.
Martin-Loeches, Ignacio, & Torres, Antoni. (2014). Are preoperative oral care bundles needed to prevent postoperative pneumonia?, Editorial, Intensive Care Medicine, pp. 109-110. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=asx&AN=92724508&authtype=athens&site=eds-live&scope=site
5.
El-Solh, A. A., Pietrantoni, C., Bhat, A., Okada, M., Zambon, J., Aquilina, A., & Berbary, E. (2004). Clinical Investigations in Critical Care: Colonization of Dental Plaques. A Reservoir of Respiratory Pathogens for Hospital-Acquired Pneumonia in Institutionalized Elders. Chest, 1261575-1582. doi:10.1016/S0012-3692(15)31374-X
6.
Fuchshuber, P. R., Greif, W., Tidwell, C., Klemm, M. S., Frydel, C., Wali, A., . . . Clopp, M. P. (2012). The power of the national surgical quality improvement program, achieving a zero pneumonia rate in general surgery patients. Permanente Journal, 16(1), 39–45.
7.
Robertson, T., & Carter, D. (2013). Oral intensity: reducing non-ventilator-associated hospital-acquired pneumonia in caredependent, neurologically impaired patients. Canadian Journal Of Neuroscience Nursing, 35(2), 10-17.
8.
Halm, M. A., & Armola, R. (2009). Effect of oral care on bacterial colonization and ventilator-associated pneumonia. American Journal Of Critical Care: An Official Publication, American Association Of Critical-Care Nurses, 18(3), 275-278. doi:10.4037/ajcc2009842
9.
Johnstone, L., Spence, D., & Koziol-McClain, J. (2010). Oral hygiene care in the pediatric intensive care unit: practice recommendations. Pediatric Nursing, 36(2), 85-96.
10. Akutsu, Y., Matsubara, H., Shuto, K., Shiratori, T., Uesato, M., Miyazawa, Y., & ... Miyauchi, H. (2010). Original Communication: Pre-operative dental brushing can reduce the risk of postoperative pneumonia in esophageal cancer patients. Surgery, 147497-502. doi:10.1016/j.surg.2009.10.048 11. Bergan, E. H., Tura, B. R., & Lamas, C. C. (2014). Impact of improvement in preoperative oral health on nosocomial pneumonia in a group of cardiac surgery patients: a single arm prospective intervention study. Intensive Care Medicine, 40(1), 2331. doi:10.1007/s00134-013-3049-y
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Dispelling Palliative Care Myths Johnathan B. Phillips, MSN, MSEd., RN-BC - 10S Palliative Care According to the National Quality Forum (NQF), "Palliative care generally refers to patient- and family-centered care that optimizes quality of life by anticipating, preventing, and alleviating suffering across the continuum of a patient’s illness."1, p. 2 The NQF projected that palliative care programs in U.S. hospitals have grown by 125 percent in the last decade (2012). Carilion Roanoke Memorial Hospital's Palliative Medicine Unit initially opened with four beds in August 2009 and increased to ten beds on October 1, 2016. Through the years, the unit’s nurses have identified misconceptions about palliative care. The purpose of this article is to provide accurate information about Carilion’s Palliative Care Unit. MYTH: Palliative Care patients must be Do Not Resuscitate (DNR) and comfort care only. TRUTH: All code statuses are allowed on Palliative Care. Most patients are full DNR, but symptom management enables them to enjoy life and spend quality time with family and friends. Bipap and high flow oxygen may be used in Palliative Care. Vasopressors and Inotrope infusions may be continued in Palliative Care with the goal of discontinuation. Terminal extubations may be performed. MYTH: Palliative Care patients do not receive medications or treatment. TRUTH: Medication regimens may be simplified and aligned to patients’ preferences, but not all medications are discontinued. Symptom management is accomplished through medication management, as well as non-pharmacological approaches, such as positioning and use of fans, and integrative therapies, like Reiki, guided imagery, music, and pet therapy. Activities of daily living are provided, such as bathing, mouth care, and skin care. MYTH: Palliative Care patients are unresponsive. TRUTH: Patients may become or be unresponsive. Educating families and caregivers is a priority while guiding them through the dying process. Many patients are responsive. It is important that palliative patients and their families participate in their plan of care, including activities related to their nutrition, exercise, and spiritual and mental well-being. MYTH: Palliative Care patients do not receive lab testing or therapies. TRUTH: A transfer to Palliative Care does not mean that all care will be stopped. Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy work with many Palliative Care patients. Speech Therapy can evaluate a patient’s swallowing abilities to determine the safest diet and feeding techniques. Some patients still require lab draws for medication and symptom management. MYTH: Palliative Care patients are starved to death. TRUTH: Palliative patients are encouraged to eat and drink and provided with the safest diet possible. Often food is given for comfort. Most diets are modified so patients may have foods they desire. As body systems slow, fluids and food are not needed as before. Appetite, desire for food and fluids, and abilities to utilize them efficiently decrease2. Few nutrients are absorbed from any type of nutrition. Fasting is a more appropriate term for what happens as death nears. Patients facing end-of-life typically do not feel hunger or thirst. A decrease in consumption and associated weight loss is a “natural progression of end-stage disease”3.
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Death as a result of loss of water and body fluids is relatively painless. Dehydration causes the brain to release opioids which may produce a sense of euphoria4.
MYTH: Palliative Care patients are given morphine and become addicted. TRUTH: Pain and symptom management are important in allowing patients to have quality of life. Medications are given only to manage symptoms and are balanced to keep patients as alert as possible so they can visit with families. Opioids, such as morphine, may be given to manage pain and other symptoms like shortness of breath. Patients and families are taught the differences between tolerance, physical dependence, and addiction. MYTH: Palliative Care is only appropriate when the patient is hours or minutes away from death. TRUTH: The Palliative Care Consult Service and Unit are open to all seriously ill patients. Palliative Care is available to all seriously ill patients regardless of their diagnosis. Palliative Care should not be viewed as a last choice or a “death sentence” but rather as a treatment choice to provide comfort to patients. Palliative Care enables patients and their families to enjoy quality of life. MYTH: Patients come to Palliative Care to die. TRUTH: There is growing evidence that shows people receiving palliative care live longer, have better outcomes, and experience improved mood, quality of life and feel better4. 30-40% of patient who come to Carilion’s Palliative Care Unit are able to discharge either home or to a facility (Table 1). Table 1:
In every setting, all nurses may provide a form of palliative care that focuses on the whole patient, providing them with quality of life and symptom management. Nurses on Palliative Care are specially trained in managing uncontrolled symptoms during serious illness and provide emotional support to patients and their loved ones as the journey through this life experience. The practice of nursing on Carilion’s Palliative Care Unit follows the REACH Professional Practice Model as well as all organizational policies, procedures, and expectations for safe patient care. The Palliative Care Unit welcomes colleagues to spend some time on the unit to observe the interprofessional approach to assessment and comprehensive management of the patient and family’s physical, psychological, social, spiritual, and bereavement needs. References 1. National Quality Forum. (2012). National voluntary consensus standards: Palliative care and end of life care - A consensus report. Washington, DC: Author. Available online at: https://www.qualityforum.org/Projects/ Palliative_Care_and_End-of-Life_Care.aspx 2. Danis, M. (2016, October 21). Stopping artificial nutrition and hydration at the end of life. UpToDate. Retrieved from www.uptodate.com/contents/stopping-artificial-nutrition-and-hydration-at-the-end-of-life? source=search_result&search=decreased%20appetite%20at%20end%20of%20life&selectedTitle=1~150
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For video from our “On the Road� events go to: http://insidecarilion.org/hubs/ nursing-research-and-evidencebased-practice/2018-week-nurseart-science-nursing-showcasevideo
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2018 Art & Science of Nursing Showcase Poster Winners Gallery! Resource MonoPOOLy Visual Award People’s Choice Award
*Winner 4 years in a row!
l-r: Brandie Bailey, Catie Neal , Becca Bishop
Postoperative outcomes in vascular surgery patients who receive non-autologous implants w/ and w/out antibiotics
Scholarship Award
Cheryl Bennett
The use of technology to decrease unplanned extubations
l-r: Pam Flinchum, Katie Hayes, Donna Bond
Judge’s Choice Award
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Advanced Nurse Training: Impact on trauma team attitudes and performance
Professional Award
l-r: Jen Bath, Daniel Freeman, Andi Wright, Kris Peters, Ellen Harvey, Dr. Mark Hamill
Mitigating opioid diversion in the hospice setting
Impact on Patient Care Award
l-r: Renee Poff, Sharon Parker
Say Yes to the Breasts: Comparing poststernotomy breast support satisfaction and wear compliance
l-r: Takako Long, Kim Bolling
Impact on Patient Care Award
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Courage! Kimberly Cockram, RN CRMH Palliative Care Unit Department for Clinical Advancement & Patient Safety Recognition The department for Clinical Advancement and Patient Safety recognized Kimberly for reporting a defective device. Based on Kimberly’s Safe Watch report, a report was issued to both the Federal Drug Administration, who oversees medical devices, as well as the product’s manufacture. From this Safe Watch report the manufacturer has made alterations to their manufacturing process to keep the defect from occurring again. This change will impact all future devices manufactured product for use across the US and beyond.
Community! Robin Lawrence, LPN Carilion Family Medicine - Hillsville Robin was voted Best Nurse of Carroll County by The Carroll News, a local newspaper. Each year residents vote on the “best” in various categories. Her colleagues write that Robin exemplifies “nursing at it’s best”. Other comments from staff include, “she is compassionate, intelligent and a tireless worker for not only our clinic but for her community as well”. Staff note that Robin has taken a leadership role in training new or ancillary employees and is the primary phlebotomist, manages supplies and sterile equipment, while working in the clinic 5 days a week.
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Commitment! Ellen Harvey, DNP, RN, ACNS-BC, CCRN, TCRN, FCCM CRMH Trauma Services Induction into the American College of Critical Care Medicine Ellen is recognized for demonstrating significant contributions and having made an impact on the profession at a regional, state, or national level. This award recognizes significant contributions to the perception, delivery, or management of the critically ill in the 3 areas of Program Development, Scholarly Contributions, and Leadership. Recipients have a minimum of 5-7 years of critical care activity after completion of training and have devoted at least 50% of time to critical care in practice, research, administration, or teaching for at least 2 years prior to applying. Ellen was also the recipient of the 2018 Regional Carolinas/Virginias Chapter Society of Critical Care Medicine Presidential Citation award. This award is given to CVCSCCM members who have demonstrated an extraordinary contribution and resources to the vision and goals of the organization and to critical care medicine.
Commitment! Sarah Beth Dinwiddie, BSN, RN CRMH Trauma Services American Red Cross Medical Hero Award Sarah Beth received the Medical Hero award from the American Red Cross for her commitment to teaching the Stop the Bleed training. Stop the Bleed is a national training initiative developed by the American College of Surgeons as a result of the Sandy Hook school shootings. It teaches bystanders how to save lives by controlling bleeding on the scene until EMS can arrive. Sarah Beth has taught school teachers, librarians, policy officers, boy scouts and Carilion Clinic staff.
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CONFERENCE CORNER
2018 VNA Spring Conference, Glen Allen, VA Lori Price, RNII-BC, preceptor for 10 Mountain PCU was invited as a panelist at the 2018 VNA Spring Conference to address nursing’s role in the opioid epidemic. Lori indicated it was an “amazing opportunity”.
l-r: Rachel Huddleston, MSN, RN; Lori Price, RN-BC; Melissa Foster, BSN, RN
2018 (ANIA) American Nursing Informatics Conference Clinical informatics specialist, Melena Roberson, BSN, RN was invited to present her poster on Optimizing Health care Through Telemedicine in Orlando, FL at the 2018 ANIA conference. The conference was attended by nurse leaders from around the country. Melena has been instrumental in developing the clinical workflows for the Telemedicine projects.
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Practical Applications of Nursing Inquiry
2018 NTI Critical Care Exposition Kim Bolling, BSN, RN, CCRN and Takako Long, BSN, RN presented their poster titled, Say Yes to the Breasts: Comparing Post Sternotomy Breast Support Satisfaction and Wear Compliance. The Critical Care Exposition is the largest, most comprehensive trade show for high acuity and critical care nurses.
American Academy of Ambulatory Care Nursing 2018 Annual Conference Lisa Myers, RN and Lydia Caldwell, BSN, RN both Clinical Care Coordinators with Carilion/Roanoke Evolent, were chosen as podium presenters at the 43rd Annual AACN Conference in Orlando, FL in May 2018. The conference brings together a unified network of ambulatory care nurses to meet colleagues, new friends and AAACN leaders. They discovered the hottest topics and practice updates from experts in the field.
l-r: Lisa Myers, RN; Lydia Caldwell, BSN, RN
The 2018 Symposium on Advanced Wound Care (SAWC) Jessica Patterson, BSN, RN CWON presented her poster in Charlotte, NC in April 2018. SAWC serves as a forum to connect the entire wound care team - physicians, nurses, physical therapists, researchers, scientists, podiatrists and dieticians - with experts in wound care to improve patient outcomes through education.
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CITATIONS & RECOGNITIONS February 2018 - June 2018
POSTERS Harvey, E., Dinwiddie, S., Lollar, D., Bath, J. Trevilian, T., Broyles, K., Shaub, Z., LaChappelle, A., Bruner, C. 2018, April 1819. Engaging employees as immediate responders to Stop the Bleed ™ in a healthcare system. 2018 Joint Commission Resources 14th Annual Emergency Prepardness Conference, Lake Buena Vista, FL. Whitehead, P. , Epstein, B., Hamric, A. 2018, April 19-21. Updating and refining a measure for moral distress. Nursing Education Research Conference 2018, Washington DC. Patterson, J., Hall, K. 2018, April 25-29. Use of negative pressure wound therapy with instillation and open reticulated cell foam with large through holes in complex wounds: A small case series. 2018 Symposium on Advanced Wound Care, Charlotte, NC. Roberson, M. 2018, May 12. Optimizing health care through telemedicine. ANIA Conference, Orlando, FL Bolling, K., Long, T., Jennings, C, Carter, K. 2018, May 21-24. A comparison of poststernotomy breast supports. NTI & Critical Care Exposition, Boston, MA Wohlford, S. 2018, March 18. Unless..... The Alliance of Nurses for Health Environments: Practice Workgroup (webinar). Bath, J. 2018, March 21-23. Decreasing trauma admission rates by implementing a call-back program. TraumaCon 2018 - Society of Trauma Nurses, Portland, OR. *Awarded Best Oral Abstract at the conference.
ORAL PRESENTATIONS Price, L. 2018, April 20. Nursing’s role in addressing the opioid epidemic. VNA Spring Conference - Panelist, Glen Allen, VA Bolling, K. 2018, April 20. Radford University School of Nursing Evening of Research, Radford, VA - Invited keynote Carter, K. 2018, April 21. Leap into your new paradigm: Exploring better ways with research and EBP. VCU Health Perioperative Conference, Richmond, VA - Invited Robertson, K. 2018, April 26-27. Essentials for development and enhancing certified stroke center programs. Mid-Atlantic Heart and Stroke Quality Summit, Raleigh, NC Caldwell, L., Myers, L. 2018, May 9-12. Advanced illness care: A patient-centered approach to end-of-life care. 2018 AAACN Conference, Lake Buena Vista, FL. Wohlford, S. 2018, June 2. A passion for sustainability. Allliances of Nurses for Healthy Environments (podcast). Availabe online at: https://envirn.org/podcast/ep-18-a-passion-forsustainability-w-sara-wohlford/ Gates, B., Musick, D., Bogue, R., Carter, K., Greenawald, M., Penwell-Waines, L. 2018, June 9-12. How emotional exhaustion, cynicism, and personal accomplishment impact personal perception of wellbeing. International Association of Medical Science Educators, Las Vegas, NV *Received Outstanding Oral Presentation Award.
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PUBLICATIONS Riegel, N, Delp, S., Ward, C. 2018, May-June 2018. Effects of Nurse-Physician Collaborative Rounding. MedSurg Nursing, 27(3), 149-152. Clark R, Carter K., Jackson J, Hodges D. July-September 2018. Audit and Feedback: A Quality Improvement Study to Increase Pneumococcal Vaccination Rates. Journal of Nursing Care Quality, 33(3), 29-296.
GRANTS Carter, K. & Clark, R. 2018, June. $118,756 from Merck Investigator Studies Program: Pneumococcus. A Quality Improvement study to increase pneumococcal vaccination rates for at-risk adults in ambulatory cardiology settings.
NOTABLE Doyle, A. (2018) Nurse Performance Reduces Suffering for Carilion Roanoke’s Coronary Patients. Published online at: http:// www.pressganey.com/Press_Ganey_Newsletter/ article-archive/industry-edge-article-archive *Note: Jeremy Fletcher, BSN, RN - Unit Director CCU/Cardiac Cath Lab is quoted in article.
RECOGNITION 2018, March. The Journal of Trauma Nursing Editorial Board announced that the second most accessed article on OVID was: Booth, K., Rivet, J., Flici, R., Harvey, E., Hamill, M., Hundley, D., Holland, K., Hubbard, S., Trivedi, A., Collier, B. (2016, September). Progressive Mobility Protocol Reduces Venous Thromboembolism Rate in Trauma Intensive Care Patients: A Quality Improvement Project. Journal of Trauma Nurses, 23(5), 284-289.
Practical Applications of Nursing Inquiry
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See Where Our Nurses Have Presented! (Since October 2014)
“The World is a book, and those who do not travel read only a page.” – Saint Augustine United Kingdom
Palm Springs
Lake Buena Vista
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Hayley Assenat is a rising senior at Roanoke College and is a Health and Exercise Science Major. A returning Intern, she also works as a Dispatcher for Roanoke College Campus Safety and recently received her Phlebotomy Technician certification. She is a member of Chi Omega Fraternity at Roanoke College where she actively participates in helping the Make A Wish Foundation. Hayley has volunteered with CRMH in multiple departments and has shadowed health professionals within the hospital as well. Her post-graduation plans are to receive her BSN and eventually return to school to receive her NP.
Our interns will be available throughout the summer. If you find you need assistance with projects, data entry, etc., please contact Beth Assenat at elassenat@carilionclinic.org and we can set up a meeting with one of our interns. Sarah Dannhardt is a rising junior at James Madison University and will be starting her first semester in the nursing program this fall. She is involved with the JMU Nursing Student Association, a club of nursing students who serve the community through fun projects, such as hosting dances for senior citizens and teaching elementary school children about healthy hygiene. Sarah has also spent time volunteering with the Red Cross and College Mentors for Kids at JMU. Her post-graduation plan is to work as a nurse in a trauma unit, and she hopes to eventually have a career as a travel nurse.
Need editorial or financial support to present your work at a national nursing conference? Contact Nursing Research & EBP for: Assistance with writing your abstract Poster development Financial support through Nightingale grants. nursingresearch@carilionclinic.
REGISTER IN CORNERSTONE FOR ONE OF OUR Nursing RESEARCH CLASSES! Basic Nursing Research for the Frontline Nurse (CE333L) August 9, 2018 - 8:00am-12:oopm CRMH 1 South Computer Room D & October 11, 2018 - 1:00-5:00pm CRMH 1 South Computer Room D ****************************
Pre-Nursing Research Fellowship Brainstorm Briefs (CE354L) June 19, 2018 - 1:00-2:00pm CRMH 1 South Computer Room D & July 18, 2018 - 4:00-5:00pm CRMH SEAY Education Ctr, 6th floor ****************************
Time to Write: Open Mentored Writing Lab (CE037L) August 21, 2018 - 1:00-5:00pm CRMH 1 South Computer Room D ***************************
Nursing Research for Leadership: Tips & Tools (CE165L) September 13, 2018 - 1:00-4:00pm CRMH 1 South Computer Room D ***************************
Developing a Competitive Abstract (CE335L) October 4, 2018 - 1:00-5:00pm CRMH 1 South Computer Room D ***************************
Advanced Research II: Methods & Statistics (CE373L) November 14, 2018 - 1:00-4:00pm CRMH 1 South Computer Room D
Advanced Research III Dissemination: Preparing for Presentations, Scholarly Writing (CE374L) January 2019 (Date and Time TBD)
Carilion Clinic Roanoke Campus