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CNL USF Conference Logo 2011

Ann Deerhake, MS, RN, CNL, CCRN


the CNL role between critical care and other areas. strategies for the development of a continuous ICU performance improvement plan.
the positive effects the CNL can have on ICU staff empowerment, financial health and patient outcomes.




the CNL role new to this facility? This setting? types of leadership and staff are present in this setting?



effect will this setting have on the CNL duties and responsibilities?

Perform Plan

advanced patient assessments

care/Change care frontline nurses

Empower Partner Grow

with the interdisciplinary team


Perform advanced patient assessments in an intensive care context Plan care/change care letting inter/intra-disciplinary input guide you

Empower frontline nurses by supporting/ debriefing them within their high stress environment
Partner with the interdisciplinary team by learning from them/anticipating their needs Grow clinically as a CNL as well as a critical care nurse


the patient

with continuity of care evidence-based practice

Promote Build

collaborative relationships up!


Empower the patient or his/her designated speaker

Assist with continuity of care especially with pulled staff

Promote evidence-based practice by encouraging frontline nurses to think beyond complacency Build collaborative relationships with all microsystem members, patients, families Speak up! Be assertive and confident


when to lead, when to follow

personal competencies

Develop Find

a common purpose and resolve barriers

Identify Set

your team apart from the rest

Know when to lead, when to follow and how to encourage others to use their strengths Develop personal competencies with realistic expectations Find a common purpose within ownership, not buy-in

Identify and resolve barriers amongst strong personalities

Set your team apart from the rest setting a role model for excellence

Develop Promote

patient safety issues/risk

realistic action plans systems thinking others to get involved



patient safety issues/risk focusing on reducing nosocomial infection

systems thinking in addition to advanced critical thinking realistic action plans utilizing frontline staff knowledge others to get involved as health promotion and safety officers




Meet Help

horizontal leadership

personal CNL goals other nurses reach their goals the profession of nursing



personal CNL goals within the context of critical care other nurses reach their goals to become facility leaders and professional nurses as well as excellent caregivers the profession of nursing and critical care nursing




what you know knowledge transfer

a coach and disseminate present

Research Formally


what you know knowledge transfer it goes both ways!


a coach and an issue resolver in critical situations and disseminate information on the fly and methodically planned present as an ICU nurse and educator



Improve Reduce


errors patient/family satisfaction recruitment/retention information using variety of

Increase Increase



Improve communication between a large, multidisciplinary team Reduce errors within a high acuity environment

Increase patient/family satisfaction within an incredibly stressful environment

Increase recruitment/retention of nurses with increased responsibility with minimal compensation Disseminate information using variety of methods and electronic technologies


improvement requires all the pieces to make a whole Assess the ICU microsystem utilizing the five P framework. Further analyze the ICU microsystem

identifying problems reviewing peer literature developing an action plan.

Purpose Mission Statement--To provide quality, compassionate care to all critically ill patients and their families; to exemplify the core values of excellence, human dignity, justice, sacredness of life and service. People/Patients Common DRGs include sepsis, respiratory and renal failure, GI bleeding, trauma/ traumatic brain injury, post-op brain surgery Focusing on those that require an external ventricular drain, i.e. hemorrhagic CVA, closed head injury, post-tumor resection

Professionals (within the microsystem) Unit manager/ Care facilitator Intensivist/Attending physicians Nurses Respiratory Care partners/Respiratory Therapy Nursing assistants/Unit Clerks Professionals (within the mesosystem) Physicians Neuroscience Clinician Social workers/Case managers Dedicated ancillary Staff, e.g. satellite pharmacy, dieticians, housekeepers

Processes External Ventricular Drain (EVD) insertion and maintenance

Patient requiring EVD admitted to SRMC EVD inserted per MD in ICU or Surgery Daily care per frontline RN Daily CT scans (or as ordered) to monitor progress Neuroscience Clinician monitors patient progress Device surveillance per Case Manager MD orders/does not order specific care of EVD Care of EVD determined by primary RNs

Patterns Risk of EVD infection No protocol for dressing changes



literature exists about EVD care Most studies discuss insertion techniques along with maintenance care Many studies discuss ICU nosocomial infection as a whole EVD infection is considered a significant risk Aseptic technique is considered integral in the prevention of EVD infection Use of distal port for sampling recommended Routine revision not recommended Most studies say number of EVDs per patient more predictive of infection than duration of each

Research Question: Would initiating a standardized protocol for EVD dressing changes in the SRMC ICU decrease incidence of nosocomial ventriculitis? Apply to IRB for EVD study approval Develop and initiate a standardized protocol for EVD dressing changes Notify neurosurgeons of study content and proposed dressing change protocol Collect EVD retrospective data from the previous 12 months Collect EVD data for the upcoming 12 months Evaluate compliance with EVD protocol Compare infection rates between groups

Developed a simple EVD dressing change protocol utilizing non-charge items ICU currently stocks: gloves, betadine swabs, drain sponges and tape as needed Notified physicians via letter regarding proposed dressing change protocol and obtain signed approval from each Educated ICU nurses, distributed orange folders and laminated protocol cards throughout ICU Collected retrospective non-intervention data and prospective intervention data

EVD/ICP Dressing Change Study Protocol Verify that patient is eligible Has an EVD/ICP in place Older than age 18 Not a prisoner

Sign consent and leave in orange folder Sign per patient or authorized representative If cannot read, read to patient/ representative If cannot speak English, use interpreter; if cannot secure interpreter services, exclude from study
Pre-dressing change preparation Check Dr. orders for alternative dressing orders Educate patient/family of need for asepsis during dressing change Assess need for sedation and/or additional nursing assistance Confirm patient with two patient identifiers

Perform daily EVD/ICP Dressing care Aseptic technique, wash hands Wear mask and non-sterile gloves Remove old dressing carefully Assess insertion site for drainage, redness or edema Change gloves Cleanse with povidine iodine swabsticks x 2, using concentric circles Allow to dry for 1 minute Place 4x4 drain sponges x 2 around EVD/ICP Secure with tape only if needed to maintain placement Monitoring and Documentation Monitor for: Signs of increased ICP Dislodgement of EVD/ICP I Increased drainage at site Document on the critical care flow sheet: Supplies used EVD/ICP insertion site assessment Aseptic technique used Patient tolerance


trial without randomization Retrospective data vs prospective data 3 designated data collectors: primary investigator, Neuro CNS and ICU Unit Manager Blinded to all but primary investigator


participant number (n=26) Single facility study


further CSF infections after daily dressing change instituted (July 2009-July 2010) rate of nosocomial ventriculitis from 54% to 0% to a savings of $44,972 decreased LOS by 127 days



Potentially Increased

patient, family and nurse satisfaction

Reduction of other nosocomial infections savings of $77,095

Reduction of device-related pressure ulcers

90% of ICU, Clinical Nurse 3 or 4

Healthier work environment t/o critical care, increased retention Collaborative competency Multiple system changes resulting in better patient care and utilization of nursing resources

Harris, J., Roussel, L., (2010). Initiating and sustaining the clinical nurse leader role. Sudbury, MA. Jones and Bartlett Publishers LLC. Korinek, A., Reina, M., Boch, A., Rivera, A., De Bels, D., & Puybasset, L., (2005). Prevention of external ventricular drainrelated ventriculitis. Acta Neurochirurgica, 147(1), 39.doi:10.1007/s00701-004-0416-z Krol, V., Hamid, N., & Cunha, B., (2009). Neurosurgically related nosocomial acinetobacter baumannii meningitis: report of two cases and literature review. The Journal Of Hospital Infection, 71(2), 176. doi: 10.1016/j.jhin.2008.09.018 Lackner, P ., Beer, R., Broessner, G., Helbok, R., Galiano, K., Pleifer, C. et al., (2008). Efficacy of Silver Nanoparticles-Impregnated External Ventricular Drain Catheters in Patients with Acute Occlusive Hydrocephalus. Neurocritical Care, 8(3), 360 - 365. doi: 10.1007/s12028-008-9071-1 Lo, C., Spelman, D., Bailey, M., Cooper, D., Rosenfeld,J., & Brecknell, J., (2007). External ventricular drain infections are independent of drain duration: an argument against elective revision. Journal Of Neurosurgery, 106(3), 378. Retrieved May 20, 2009 from MEDLINE with Full Text. Monaghan, H., Swihart, D., (2010). Clinical nurse leader: transforming practice, transforming care. Sarasota, FL. Visioninf=g Healthcare Inc. Orsi, G., Scorzolini, L., Franchi, C., Mondillo, V., Rosa, G.,& Venditti, M., (2006). Hospital-acquired infection surveillance in a neurosurgical intensive care unit. The Journal Of Hospital Infection, 64(1), 23. doi: 10.1016/j.jhin.2006.02.022