Pupillometry

Background: Measuring pupillary light reflex is a standard part of neurological assessment. Changes in pupil reactivity may indicate unfavorable outcomes, such as increased intracranial pressure and brain herniation. Physiologic and pharmacologic agents may affect pupil reactivity. In some instances, pupillary light reflex is the only piece of neurologic assessment readily testable.https://digitalcommons.centracare.com/nursing_posters/1158/thumbnail.jp

Accelerated Onboarding for Unlicensed Personnel When Preceptors Are Limited

Problem: The timeframe between hiring unlicensed personnel (UP) to beginning the role within the organization began to increase due to limited orientation resources, rising staff shortages, and insufficient number of preceptors. Purpose: Accelerate the onboarding of UPs to decrease the workload for preceptors and reduce staff shortages, while generating competence and reducing costs for the organization.https://digitalcommons.centracare.com/nursing_posters/1151/thumbnail.jp

Recognition of Nonconclusive Seizures in Patients After Cardiac Arrest Using

Background: Evidence - Prevalence of nonconvulsive status epilepticus or other epileptiform activity in patients who are comatose after a cardiac arrest is between 12-22%. Consistent with the literature, at this facility approximately 12% were found to have non convulsive seizures. Prolonged epileptiform discharges may cause secondary brain injury and increased mortality. In 2020, the American Heart Association recommended EEG monitoring should be promptly performed and interpreted for the diagnosis of seizures in all comatose patients following cardiac arrest. Local Problem - Comatose patients admitted to critical care after cardiac arrest who require targeted temperature management (TTM) have continuous EEG monitoring ordered STAT. Neurodiagnostic technologists who apply EEG monitoring are not available 24/7. Conclusions/Implications: While the rapid EEG recording may have limitations compared to continuous recordings for diagnostic purposes, it has immediate feedback for monitoring of nonconvulsive status epilepticus. Continuous EEG monitoring can take 45 minutes to set up and much longer to obtain diagnosis of status epilepticus. Continuous EEGs have broader diagnostic capabilities, however, are not monitored continuously by neurology providers, which could delay the identification of seizure activity. Recommendations: Continue immediate placement of rapid EEG if technologists are not available within one hour. Continue to replace rapid EEG with continuous EEG when technologist becomes available. Explore improved capabilities for more timely reading and diagnosis of continuous EEG.https://digitalcommons.centracare.com/nursing_posters/1159/thumbnail.jp

From Silos to Collaborative Working Relationships with EMS and ED

Opportunity: To establish a strong, collaborative relationship between St. Cloud Hospital Stroke Center, St. Cloud Hospital Emergency Department and Emergency Medical Services. Background: Two separate health care systems with one goal in mind: best stroke care for a community member experiencing stroke-like symptoms. Current Practice in 2017: Code stroke activation with LTKW (last time known well) up to 6 hours. Inconsistent pre-notifications and pre-activations by EMS and ED. St. Cloud Hospital and Mayo Clinic Ambulance with siloed/individualized protocols for their respective health systems. Conclusion: In May 2019, after 2 years of working together our teams saw our efforts come together when Mayo Clinic Ambulance adopted and supported St.Cloud Hospital VAN (visual, aphasia, neglect) protocol to be site specific for the St. Cloud Region. Our collaboration efforts have shown when there is pre-notification and pre-activation patients are treated with a thrombolytic consistently under 45 minutes and to the operating room for a thrombectomy within 75 minutes.https://digitalcommons.centracare.com/nursing_posters/1154/thumbnail.jp

Promotion of National Certification in Telemetry

Situation: Goal to bring awareness to telemetry nurses, the specialty certifications they are eligible for, and criteria for eligibility. Currently, six telemetry nurses hold a nationally recognized certification. Action Plan: March 19, 2023 was Certified Nurses Day and was the kickoff for the start of encouragement for telemetry nurses to be certified. Each telemetry nurse was delivered a card and lifesaver candy inviting them to consider a nationally recognized certification. A certification informational packet promoting CV-BC and PCCN certification was placed at each desk and referenced during huddle for one week. Certification preparation books are available upon request.https://digitalcommons.centracare.com/nursing_posters/1157/thumbnail.jp

Heated High Flow Oxygen Therapy Management of Respiratory, Swallowing/Dysphagia and Nutrition Needs

Problem Patients diagnosed with COVID-19 pose challenges for oxygenation. Often requiring heated high flow oxygen therapy (HHFOT) for days to weeks, with literflow commonly over 40 L/min with maximum of 60 L/min. There is minimal research on aspiration risk at higher literflow, therefore practice included decreasing liter flow to 20 L/min for oral intake was standard. During oral intake, with literflow decreased to 20 L/min, patients\u27 oxygen saturations would quickly trend down. Alarms indicating low saturation would create anxiety, cause patients to eat faster potentially increasing risk for aspiration. Solution For adult inpatients meeting criteria, increase maximum literflow allowed during oral intake from to 40 L/min. Develop guidelines for: oxygen supplementation during oral intake how/when to consult Speech Language Pathologist inclusion of dietitian earlier in hospitalizationhttps://digitalcommons.centracare.com/nursing_posters/1155/thumbnail.jp

Dynamic Bronchoscopy for Excessive Dynamic Airway Collapse

Definition: Excessive Dynamic Airway Collapse (EDAC) is a respiratory condition characterized by \u3e50%luminal narrowing on expiration.https://digitalcommons.centracare.com/nursing_posters/1153/thumbnail.jp

Safe Intra-Hospital Transport of Adult Patients on Non-Critical care Units

Plan: Between 2021 and 2022, two non-critical adult patients returning from the imaging department after an invasive procedure developed increased oxygen needs, which ended in death for on patient and a transfer to critical care for the other. No formal guidelines exist for the intra-hospital transport by unlicensed personnel may be absent. An intra-hospital transport checklist was developed for non-critical care patients leaving the unit for procedures in the imaging department. Do: A RN Pre-Invasive Procedure Transport Safety Checklist was created by a telemetry RN (MSN student, Greta Titus) and CNS, Teresa Jahn The checklist was designed to answer questions to determine a patient\u27s hemodynamic and respiratory stability prior to transport by an unlicensed person The checklist is to be completed prior to transport on all patients leaving the unit for a procedure in the imaging department (i.e. paracentesis, thoracentesis, biopsy, etc.) If one of the questions answered is yes , the next step is to prompt a huddle with Resource RN or Charge RN to identify f a patient is safe for transport without a RN. The why for the change was presented by Greta Titus during the November 2022 CentraCare Heart and Vascular Center Clinical (CCHVC) Practice meeting Staff were also notified of this change during Telemetry daily huddles and weekly updates The trial started on Telemetry beginning 11/1/2022 Follow up on the progress of the practice change was presented by CCHVC CNS during Telemetry Education Days in January-February 2023https://digitalcommons.centracare.com/nursing_posters/1161/thumbnail.jp

Clinical Nurse Specialists: A Rare Breed

What is a CNS?: A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) with graduate level education in nursing. CNSs are prepared to provided leadership, consultation, and clinical expertise for patients and their families, nurses, and systems. Have the autonomy to diagnose and treat based on advanced clinical assessment like other APRNs (Nurse practitioners, certified nurse midwives, certified registered nurse anesthetists). CNS work in all areas of healthcare like clinics, emergency departments, hospital units, entire healthcare systems, or even as independent practitioners/contractors.https://digitalcommons.centracare.com/nursing_posters/1152/thumbnail.jp

Transitions to Normal Saline ONLY for CVADs

Purpose Statement: The purpose of this project is to implement a practice change throughout the system to remove heparin flushes for Central Venous Access Devices (CVADS) pending a successful pilot on Medical Oncology. Synthesis of Evidence: Shama et al (2019) conducted a systematic review and meta-analysis including 886 participants that revealed no clear differences in CVC patency between heparin and NS. Klein et al (2018) conducted a pilot study on a 30-patient bone marrow transplant unit, each patient had a new CVC and were divided into two groups. Among 698 catheter-associated events overall incidence of central line issues were similar in both heparin and normal saline group. Egnatios & Gloria (2021) studies 37 patients receiving clinical trial infusions, they divided the study into two phases. During heparin phase there were 302 port accesses and four alteplase orders, during the NS study there was 261 accesses and seven alteplases orders. Alteplase was successful every time it was used. Zhong et al (2017) performed systematic [sic] review on use of heparin v. flushing protocols. Ten randomized control trials involving 7,785 participants were included in the meta-analysis. No general differences found between heparin v. NS in maintaining patency. Goossens et al (2013) oncology patients were randomly selected from 2009-2011. 382 were ultimately selected for normal saline group, and 283 for heparin group. All nurses were trained in proper pulsatile technique before study, it was found intimately heparin was not superior in comparison to NS in maintaining the patency of CVC.https://digitalcommons.centracare.com/nursing_posters/1164/thumbnail.jp