Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Reducing central line-associated bloodstream infection in contaminated central venous catheters: case studies of a pediatric contamination guideline.

Healthcare organizations have prioritized patient safety and quality improvement efforts to reduce central line-associated bloodstream infections (CLABSIs). Implementation of central venous catheter (CVC) insertion and maintenance bundles have significantly reduced infection rates. Nevertheless, CLABSIs continue to be a significant cause of mortality and morbidity in hospitals, and further efforts are necessary to improve CVC care practices. A hospital-wide committee at a tertiary care pediatric hospital identified gaps in our CVC maintenance practices resulting from CVC contamination events from a patient's body fluids. A lack of published literature on the topic resulted in the need to create an institutional clinical practice guideline (CPG) to develop guidance to mitigate potential CLASBIs from CVC contamination. Utilization of the CVC CPG in all inpatient units and other reduction strategies resulted in a steady decline in our CLABSI rates, particularly in those related to CVC contamination events. Case reports illustrate the effectiveness of the CPG.

A Prospective Study of Family Engagement for Prevention of Central Line-associated Blood Stream Infections.

INTRODUCTION: We sought to determine if a family-centered care (FCC) handout intervention designed to encourage family engagement (FE) in the prevention of central line-associated bloodstream infections (CLABSIs) would alter parental perceptions of FCC and improve staff compliance with CLABSI bundle components. METHODS: A prospective quasiexperimental study of 121 legal guardians of children with a central venous catheter (CVC) admitted to the pediatric intensive care unit (PICU). Baseline (n = 59) and intervention (n = 62) groups of parents completed an 18-question online survey assessing basic CLABSI care practices and FCC principles. The intervention group received an FE handout before completing the survey with information about CLABSI prevention practices designed to encourage active participation in their child's CVC care. RESULTS: Independent sample t-tests found significant improvements in the intervention parents responses compared to the baseline group (no handout) on survey items assessing CLABSI knowledge (P < 0.001) and on parental perceptions of FCC in the domains of dignity and respect, information sharing, participation, and partnership (all with a P < 0.001). An improvement was observed in staff CLABSI maintenance bundle compliance in the postintervention period, increasing from 89% to 94%. CONCLUSIONS: Educating parents on CLABSI prevention strategies and encouraging family participation in CVC care was associated with improved parental perceptions of participation in their child's care, medical team's listening, attention, honesty, and explanation of treatment plans and was associated with an increase in staff compliance with CLABSI maintenance bundle practices.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

CE: How to Predict Pediatric Pressure Injury Risk with the Braden QD Scale.

: The Braden QD Scale is a conceptually based, pediatric-specific, risk assessment instrument that reliably predicts both immobility-related and medical device-related pressure injuries in the pediatric acute care environment. A revision and simplification of the commonly used Braden Q Scale, the Braden QD Scale can be used to assess risk among the wide range of infants, children, and adolescents commonly treated in acute care environments. As part of a comprehensive program to prevent hospital-acquired pressure injuries, the Braden QD Scale promotes patient safety, quality of care and care monitoring, and effective resource use in pediatric hospitalized patients. The authors provide guidance on using the Braden QD Scale to assess pediatric patients and score their risk of pressure-related injury in numerous scenarios frequently encountered in acute care practice.

Predicting Pressure Injury Risk in Pediatric Patients: The Braden QD Scale.

OBJECTIVE: To describe the development and initial testing of the Braden QD Scale to predict both immobility-related and medical device-related pressure injury risk in pediatric patients. STUDY DESIGN: This was a multicenter, prospective cohort study enrolling hospitalized patients, preterm to 21 years of age, on bedrest for at least 24 hours with a medical device in place. Receiver operating characteristic curves using scores from the first observation day were used to characterize Braden QD Scale performance, including areas under the curve (AUC) with 95% CIs. RESULTS: Eight centers enrolled 625 patients. A total of 86 hospital-acquired pressure injures were observed in 49 (8%) patients: 22 immobility-related pressure injuries in 14 (2%) patients and 64 medical device-related pressure injuries in 42 (7%) patients. The Braden QD Scale performed well in predicting immobility-related and medical device-related pressure injuries in the overall sample, with an AUC of 0.78 (95% CI 0.73-0.84). At a cutoff score of 13, the AUC was 0.72 (95% CI 0.67-0.78), providing a sensitivity of 0.86 (95% CI 0.76-0.92), specificity of 0.59 (95% CI 0.55-0.63), positive predictive value of 0.15 (95% CI 0.11-0.19), negative predictive value of 0.98 (95% CI 0.97-0.99), and a positive likelihood ratio of 2.09 (95% CI 0.95-4.58). CONCLUSIONS: The Braden QD Scale reliably predicts both immobility-related and device-related pressure injuries in the pediatric acute care environment and will be helpful in monitoring care and in guiding resource use in the prevention of hospital-acquired pressure injuries.

Maintaining Interrater Agreement of Core Assessment Instruments in a Multisite Randomized Controlled Clinical Trial: The Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) Trial.

BACKGROUND: RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) was a cluster randomized clinical trial evaluating a sedation strategy in children 2 weeks to <18 years of age with acute respiratory failure supported on mechanical ventilation. A total of 31 U.S. pediatric intensive care units (PICUs) participated in the trial. Staff nurse rater agreement on measures used to assess a critical component of treatment fidelity was essential throughout the 4-year data collection period. OBJECTIVE: The purpose of the study is to describe the method of establishing and maintaining interrater agreement (IRA) of two core clinical assessment instruments over the course of the clinical trial. METHODS: IRA cycles were carried out at all control and intervention sites and included a minimum of five measurements of the State Behavioral Scale (SBS) and Withdrawal Assessment Tool-Version 1 (WAT-1). Glasgow Coma Scale scores were also obtained. PICUs demonstrating <80% agreement repeated their IRA cycle. Fleiss's kappa coefficient was used to assess IRA. RESULTS: Repeated IRA cycles were required for 8% of 226 SBS cycles and 2% of 222 WAT-1 cycles. Fleiss's kappa coefficients from more than 1,350 paired assessments were .86 for SBS and .92 for WAT-1, demonstrating strong agreement and similar to .91 for the Glasgow Coma Scale. There was no difference in Fleiss's kappa for any of the instruments based on unit size or timing of assessment (earlier or later in the study). For SBS scores, Fleiss's kappa was significantly different in larger and smaller PICUs (.82 vs. .92, p = .003); however, Fleiss's kappa for both groups indicated excellent agreement. CONCLUSION: Monitoring measurement reliability is an essential step in ensuring treatment fidelity and, thus, the validity of study results. Standardization on the use of these core assessment instruments among participating sites was achieved and maintained throughout the trial.

The Advanced Practice Clinical Nurse Specialist.

The clinical nurse specialist (CNS), one of the 4 advanced practice registered nurse (APRN) categories, has a unique role to play in contributing to high-quality patient care and system-level change across multiple health care settings. CNS practice requires advanced knowledge and skills, including specialty expertise, the ability to integrate new knowledge and innovation into the system of care, the ability to consult and collaborate with all health professions, and the mentoring of nursing staff to support and fully implement that new knowledge. The purpose of this article was to describe the role of the CNS, explain the background of the CNS role as it relates to APRN practice, provide current CNS workforce statistics, and share opportunities for hospitals and health systems to strategically use CNSs to advance patient and organizational goals.

Implementation of a professional portfolio: a tool to demonstrate professional development for advanced practice.

The literature has a gap related to professional development for APRNs. In the United States, many health care organizations use clinical advancement programs for registered nurses, but APRNs are not often included in these programs. If APRNs are included, advancement opportunities are very limited. At CMC, implementation of a professional portfolio resulted in increased satisfaction among APPs regarding their ability to showcase professional growth and expertise, as well as the uniqueness of their advanced practice. Use of the professional portfolio led to improved recognition by APS and organizational leaders of APP performance excellence during the annual performance evaluation, as well as improved recognition among APP colleagues in terms of nominations for honors and awards.