A multidisciplinary team designed a clinical pathway that improved institutional practice and quality of care.

Unsuccessful extubation can increase critical care unit and hospital length of stay, hospital costs, the need for tracheostomy, the risk for developing pneumonia, and morbidity and mortality rates.

After noticing high rates of postextubation stridor among patients in the University of Maryland Medical Center's 22-bed neurocritical care unit, an interdisciplinary team of providers at the Baltimore hospital developed and implemented a clinical pathway that led to sustained changes in practice and contributed to improved extubation outcomes for patients in the unit.

"Multidisciplinary input and support was critical at every stage of this initiative," the study's co-author Megan Lange, DNP, ACNP-BC, acute care nurse practitioner in the NCCU, says in a news release. "Our aim was to affect institutional practice and improve the quality of care provided in the NCCU. By working together, we were able to provide more consistent care and improve our rates of successful extubation."

Multiple Factors to Success
 

The study, "Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor," published in the October issue of Critical Care Nurse, gives an overview of the quality improvement project and shares results from the initial 12-week implementation.  

Outcomes included a significant reduction in overall rates of postextubation stridor, reintubation, and reintubation due to postextubation stridor.

Changes in practice occurred as well, including:

• Regular assessment of patient risk factors
   
• Use of inhaled budesonide in high-risk patients
   
• Consistent use of a single-dose steroid for high-risk patients

The researchers say determining which individual change had the greatest impact or whether confounding variables contributed to the outcomes is difficult.

For example:

• Greater attention to extubation criteria may have prevented premature extubation
   
• Use of a single-dose steroid may have contributed to the overall reduction in duration of mechanical ventilation, decreasing the risk for postextubation stridor
   
• Decreased duration of intubation may have decreased the risk for ventilator-associated pneumonia that could require reintubation.
   

Interdisciplinary Teamwork
 

The interdisciplinary team consisted of a neurocritical care intensivist, a neuroanesthesiologist, a neurocritical care fellow, a pharmacist, two NPs, and a physician assistant.

The clinical pathway incorporated available research to create consistency in evaluation of patients receiving mechanical ventilation before extubation and to guide decisions regarding care and treatment.

Before implementing the pathway, all prescribing providers in the neurocritical care unit received training on its use. All NPs, PAs, and neurocritical care fellows had additional one-on-one training on the checklist that outlined the clinical pathway.

During morning rounds, the checklist was to be completed for every intubated patient. While all providers participated in decision-making based on the clinical pathway, the NP or PA assigned to each patient was responsible for completing the checklist.

The implementation phase of the study lasted 12 weeks and weekly updates were posted to encourage compliance and reinforce the training.

During the study period, the pathway was completed on all intubated patients daily, with a total of 606 days of mechanical ventilation and an overall compliance rate of 88%. Of the 56 patients extubated during the trial:

• 54 had a checklist completed, for 96% compliance on the day of extubation
   
• Five extubations resulted in stridor
   
• A total of three reintubations were not associated with stridor
   
• No reintubations were performed because of postextubation stridor
   

There are plans to permanently implement the pathway and add it to the electronic medical record to decrease paperwork and help reduce workload.

Parsing out the variables that make up nursing shortage numbers will help nurse leaders make sense of the shortfall. It's really all about the details.

"The 30,000-foot view" is a popular phrase used to encourage others to see the big picture. But is assessing the nursing shortage from a Mount Everest-like vantage point a good idea? Yes and no.

While understanding national trends in the nursing workforce and nursing education is necessary, overlooking the finer details, such as what's occurring in specific geographic areas or specialties, ignores the complexities of nurse supply and demand.

"The shortage is not just one thing. There are a lot of different things that are playing into what the shortage is," says Heidi Sanborn, DNP, RN, CNE, clinical assistant professor and interim director of the RN-BSN, and concurrent enrollment program in the College of Nursing and Health Innovation at Arizona State University in Phoenix.

Sanborn shares five observations on the nursing shortage that should be considered in the shortage forecasts. 

1. There's No Standard Shortage
 

"The shortage will not hit all areas the same. In some states, it is very regional, and some states are projected to have worse shortages than others. Some states are predicted to have a glut of nurses so there will be no shortages there at all. [Based on] the latest data, the big predictions for the shortage in the next 10 years are California, Texas, surprisingly New Jersey, and South Carolina. They are really the top at the moment for predicted shortages. We are still bracing for shortages here in Arizona, but we are now hearing that it may not be as bad as we thought it was originally predicted to be."

2. It's Not Just Acute Care
 

"When we think nursing, we tend to think of a nurse going into a hospital in the morning, reporting for his or her 7 a.m. to 7 p.m. shift at the bedside, and we tend to call that bedside nursing. Nursing is shifting, so the shortage isn’t necessarily happening in that traditional [hospital] market. A lot of new worlds are opening up, and those new worlds are really struggling to attract nurses [to work] away from the bedside, particularly BSN-prepared nurses. Some of the emerging markets that we are seeing in nursing are areas like assisted living and senior housing.

Reimbursement is shifting away from the hospital, and what that means is that everybody benefits from keeping patients out of the hospital. As a result, we have less patients staying in the hospital or [their stays are shorter]. But those patients still have complex care needs.

Assisted living, senior housing, retirement communities—they [all] want BSN nurses who are prepared to manage these patients autonomously, working independently outside an environment where you might have a physician or nurse practitioner sitting right next to you to write an order. Those markets are struggling to attract nurses.

When I talk to new grads or prospective students they say, "I am going to work in a hospital in a pediatric intensive care unit." But those aren’t where all the jobs are. So, nursing itself is going through a shift, and that is what is shifting our definition of what the nursing shortage looks like."

3. Schools of Nursing Are Affected
 

"When we talk about the nursing shortage, we talk about baby boomers. Nursing is an aging workforce that is preparing for retirement. This is particularly hitting nurse faculty hard. [Nursing Schools] by default, have an older workforce than the traditional bedside nursing workforce, so we are being hit much more strongly with a retirement boom.

The pipeline for getting a new faculty member into a faculty position [takes longer]. They need to have clinical experience. They need to have a master’s degree, at a minimum, if not a doctoral degree. So by default, we attract older nurses to be nursing faculty.

With retirements, we do not have enough nurses coming up through the career pipeline to fill the [faculty] shortages that are going to happen. Without nursing faculty, we are going to struggle to get new nurses to the bedside who can fill that pipeline."

4. Specialty Makes a Difference
 

"The nursing shortage encompasses nurse practitioners as well. One interesting example is behavioral health providers. They are all lumped into one group, so nurse practitioners or nurses who are certified in behavioral health are not [counted as] a separate group. When you separate out nurses and nurse practitioners from that [group] we realize we do not have enough [behavioral health] providers.

And, of course, there is an increased focus at the national level [with] the opioid crisis and medication- assisted therapy, [and] nurse providers and nurse practitioners treating patients with mental health issues and substance abuse issues. We do not enough providers to do that right now.

When you break the nursing shortage down by discipline or by bedside practice or advanced practice, it looks very different when you examine those populations of nurses separately from a larger group. So, the nursing shortage numbers that we see don't always adequately explain where the shortages are."

5. It Could Further Diversity
 

"Nursing schools and nursing employers are looking at increasing diversity in our workforce. Our patient population is extremely diverse, but our nursing care providers are not. We struggle to attract men. We struggle to attract racially and culturally diverse providers. In the faculty realm, we struggle with that as well. Nursing researchers are overwhelmingly white and female.

We have got to do something, and we are trying hard to change that mix. With the shortage we have a great opportunity to get creative about who are we attracting. How can we increase those markets of potential nurses and engage them in the profession?"

The Early Feeding Skills checklist accounts for the multiple skills infants need to feed successfully.

A key factor in determining when premature infants can be discharged home from the hospital is the establishment of oral feeding.  But for premature infants and those with medical problems during the neonatal period, learning to feed safely can be a challenge.

"For preterm infants and those with medical complexities, early feeding skills are in a state of emergence while receiving neonatal care. Selecting appropriate and supportive interventions begins with thorough assessment of the infant's skills," writes Suzanne Thoyre, PhD, RN, FAAN, of the University of North Carolina at Chapel Hill School of Nursing and her co-authors in new study in Advances in Neonatal Care.

Through their study, Thoyre and her colleagues determined the Early Feeding Skills checklist to be an effective way for nurses and other healthcare professionals to evaluate preterm infants' emergence of feeding skills.  

According to the research, the EFS is a user-friendly tool for assessing and monitoring feeding skills in premature infants and other infants at risk of feeding problems and for guiding interventions to promote the skills needed to successfully feed.  

The 22-item checklist can be used to assess oral feeding skills in infants feeding by breast or bottle. For the study, registered nurses, speech-language pathologists, and occupational therapists used the EFS to evaluate the feeding skills of 142 infants at children's hospitals in three states. Three-fourths of the infants were born prematurely while some were full-term infants who had undergone heart surgery.  

The researchers identified a set of five subscales measured by the EFS:

1. Respiratory regulation (the ability to coordinate breathing and sucking)
    
2. The ability to organize oral-motor function
    
3. Swallowing coordination
    
4. Staying engaged with feeding
    
5. Remaining physiologically stable during feeding
    

Other assessments have focused on the volume of feeding or individual skills but did not account for the complexity and interaction of skills needed for effective feeding. 

"The EFS provides a reliable and valid way to systematically observe and record the maturation of [infants'] feeding skills and guides the selection of interventions to optimally support their skill trajectory," Thoyre and her colleagues conclude.

Poor quality resuscitation is preventable. 

Each year, more than 200,000 adult cardiac arrests occur in U.S. hospitals and less than 26% of those patients survive, says the American Heart Association. Additionally, survival rates vary from hospital to hospital.

Could this be related to the way CPR education has traditionally been provided? To remain current in basic life support, healthcare providers only need to complete CPR training every two years. But studies show CPR skills can deteriorate within three to six months following this training, reports the AHA.

"If you took piano lessons, you wouldn't practice once and then do a concert a year later," says Gregory Norton, MHA, EMT-P, staff development senior coordinator at The Ohio State University Wexner Medical Center in Columbus, Ohio. "You'd practice every few weeks or every few months to keep your skills up."

Which why the AHA, in conjunction with Laerdal Medical, developed Resuscitation Quality Improvement, a self-directed, simulation-based performance and quality improvement program for healthcare professionals.

Besides improving CPR quality, the AHA has a goal to save 50,000 addition lives from preventable cardiac arrest death each year by 2025 through this new style of competency training.

OSU Wexner Medical Center has been involved in the RQI program for about four-and-half years, and Norton sits on the RQI stakeholders advisory board.

Here's how the quality improvement works.
 

  1. High-Frequency Training
 

"RQI utilizes burst training, or [also referred] to as low-dose, high-frequency training," Norton explains. Healthcare professionals take part in hands-on CPR skills practice in 10 minutes every 90 days via a manikin connected to a computer system that provides real-time feedback on CPR metrics such as:

• Compression rate
   
• Depth
   
• Compression release
   
• Compression fraction

"You spend anywhere from about 5 to 15 minutes practicing your CPR skills and going through some cognitive content just to review the protocols and the dynamics of CPR and resuscitation in general," Norton says. "Instead of doing that annual or biannual education, where you're in class for a few hours, the short increments of training every three months mean you're constantly refreshing your skills."

The real-time feedback has also helped staff members make adjustments to improve their technique.

"We've got about 2,000 employees using the program now, and we have been successful at working with individuals that do struggle with the exercise, " he says. "We find ways to accommodate them whether it's getting a step stool or adjusting the height of the manikin. We've got one staff with arthritis, and she knows that she's got to put her wrist brace on when she's going to do her compression activity."
 

   2. Easily accessible

Unlike traditional CPR training, RQI is available 24/7. At one hospital in the OSU WMC system, there are two carts that rotate through different units once a month, says Norton.

The rotation schedule is published so staff can either wait until the cart is on their unit that month or they can visit the cart on another unit. This allows sessions to be incorporated into staff members' typical work schedules.

"You're not having to leave the building and drive to our education center the way you would for a traditional class," Norton says.

At OSU WMC East Hospital in Columbus, the RQI cart was intentionally placed in an easily accessible common area.

"The one my department uses is right next to the gift shop and the bathroom. If my staff can get down to the gift shop every day, they can certainly get to the [RQI cart]," says Carol Gray, RN, assistant nurse manager at OSU WMC East Hospital.
 

  3. Tracking and Compliance

Gray says it is not difficult to track metrics and compliance with training.

"I was able to set up a report that would show up on my desktop twice a week, and then I could run it through it and just see who's compliant and who's not," she says.

Unit managers must also communicate with the RQI administration, in this case, it would be Norton, to make them aware of staff members who are on leave, who have resigned, or who are just starting.

Norton says Gray's team is one of the highest performing in terms of compliance rates, consistently scoring 99% to 100%.

Gray says that enlisting the support of "self-identified champions" has contributed to the successful compliance rates.

"I provide them with the list of who's completed and who's hasn't, and [the champions]  take it upon themselves to either encourage [the nurses] to get downstairs [to the RQI cart] on their own, or to actively take them downstairs," she says.  

Friendly competition also helps with compliance.

"We have a company here in Columbus that makes very good cookies, and I said, 'If you get [the training] done in the first 30 days that the module comes out, I will buy the department—if everyone in the department's done—the cookies," she says.

Results
 

In addition to completion of the training, the system also tracks skills performance. The RQI system creates a score for each user based on chest compressions. A minimum passing score is 75%.

"We consistently are well above that," Norton says. "Over the last three to four years, our average score for all attempts was in the 80% to 88% range."

Individual attempts are also consistently above average.

"When we look at our high scores, which is usually the final score that a person records, our high scores are consistently in the 88% to 92% band," he says. "Although, we routinely have individuals that are performing at an even higher level. A lot of our staff take it as a point of pride. They want to hit that high score. They want to see 95%, 98%, 100%."

This has translated to an increase in overall skills quality, Norton says.

"The more time you can spend on chest, the better outcomes are predicted to date, so we want to see a high compression fraction," he explains. "When we reviewed the compression fractions of the staff that's been on RQI, after one year of using the program, they went from 82% to 91%."

Norton points out that poor quality CPR is a preventable harm that can be addressed. 

"Regardless of how long you've been in healthcare, if you're not training the appropriate way, and you're not getting positive feedback during that training, then there's probably room for improvement," he says. "Finding a more efficient way to train staff and to ensure that we're training them appropriately, should improve the overall resuscitation skills."