practice with purpose and passion - amazon web...

11/4/2016

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Practice with purpose & passion

Mary Kay Bader RN, MSN, CCNS, FAHA, FNCS [email protected]

• AANN • Past Past President

• NCS BOD: Secretary • Medical Advisory Board

• Brain Trauma Foundation • Neuroptics

• Scientific Advisory Board • Cerebrotech • Sage Therapeutics

Disclosures

Concepts Practice

Essence of Teamwork Shared Decision making Communication Collaboration

Purpose

Passion

Overview

What is at the core of our work? Practice

Nurses and Team members actions are directed toward distinct goals

Assisting our patients overcome illness

or injury by assessing, implementing and evaluating our care

Takes those in our care to a better

place

Themes

What is at the core of our work? Purpose

Oxford dictionary “the reason for which something is done or created; a person’s sense of resolve or determination.”

As health care providers, our intent and

determination contributes to the quality of our patient’s recovery and experience while in our care.

Themes

What is at the core of our work? Passion

Vision Statement: The American Association of Neuroscience

Nurses (AANN), as the leading authority in neuroscience nursing, inspires PASSION in nurses and creates the future for the specialty.

It is the fuel that drives us in our work

Themes

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How do we integrate these concepts into what we do in the clinical environment and make a difference in our Patient’s Lives?

Practice

Purpose

Passion

PRACTICE What does it take come together as a Team in Clinical Practice?

Manser1 defines teams as ”two or more individuals who work together to achieve specified and shared goals, have task-specific competencies and specialized work roles, use shared resources and communicate to coordinate and to adapt to change” (p.143).

Essential Elements of the Team What is the Problem?

Making patients better is a team sport and not everyone on the team is “ON” the team.

My Team My Team Neurosurgery

Trauma Surgeon

Intensivist

Nurses/Therapists

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My Team

Physician Specialties Neuro: Trauma, Emergency

Department, Anesthesia Neurosurgery, Neurology, and Intensivist

Nursing Leadership Director/Manager from various units APNs: Clinical Nurse Specialist/NP Staff Nurses

Other disciplines Respiratory Pharmacy Social Work/Care Manager Chaplain

Working together as a Team…

Critical elements Team performance is vital to safely and

effectively implement coordinated care Many teams work in a rapidly changing

environment, i.e., Stroke Teams, with multiple specialties moving in and out

These teams work as ACTION TEAMS integrate diverse professional cultures under

conditions which are constantly changing as they care for critical, often unstable patients

Essential Elements of the Team

Action Teams: Master 3 distinct elements Team practice together

Various disciplines contribute unique interventions and skill sets to the patient care environment

Each team member must be present to provide the knowledge and skill that is unique to their profession

Provide a seamless delivery of care across different care units in a coordinated, effective manner


Essential Elements of the Team Barriers to team performance

Toma9 studied 43 hospitals to identify barriers to implementing HACA Team members lacked familiarity with concrete

protocols Several process issues produced barriers including

lack of agreement within teams of the evidence supporting hypothermia

lack of interdisciplinary collaboration between ED and intensive care units (ICU)

increased workload demands for ED nurses lack of interprofessional education between nurses and

physicians Complexity of care delivered in mild hypothermia is

identified as a key concept that raises a barrier to implementation (seen in sepsis studies)

Ability of a team to successfully blend the individual member contributions require Teamwork Leadership/ Shared decision making Effective communication Collaboration


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#1 Teamwork Builds safer environment by decreasing

errors in the delivery of care Forming a Team takes TIME and has 4

stages Develop and learn acceptable behaviors Counter dependency and conflict where issues

such as power, competition and authority are questioned

Develop trust, increase collaboration as a team, and open discussions of each members roles and responsibilities

Effective group productivity

#1 Teamwork

Essential ingredients that produce improved patient outcomes Quality of collaboration amongst

practitioners needs to demonstrate mutual respect and trust

Strong shared goals as well as view the situation in a similar way and understand team structure and roles


#1 Teamwork

Coordination of care

Communication is open with a shared frame of reference and encompasses team meetings or briefings

Leadership within the team values contributions made by all members and engages each member is participating in the decision making process Case: 43 year old SAH Transfer


#2 Leadership/Shared Decision Making Successful action leaders possess the

following behaviors: encourage team input state and evaluate plans assert opinions when needed listen to staff’s comments delegate tasks appropriately prioritize the care interventions assess each team member’s ability to

perform tasks


Leadership?

Lessens from the gridiron… Team + Champion = Super Bowl

=

Leadership?

Lessens from the gridiron… Team - Champion

= -

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#2 Leadership/Shared Decision Making

Studies on effective leadership In video recorded resuscitation, researchers

found that a team was less dynamic and adaptable if the leader assumed a “hands-on” role… teams were not as effective (Manser et al)

When a senior nurse or physician arrives and demonstrates more directive behaviors such as coordinating the team and interventions, the team performance is evaluated as “optimal” (Reader et al)

Manser T. Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta

Anaesthesiol Scand. 2009;53:143-151. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team

performance framework for the intensive care unit. Crit Care Med. 2009;37:1787-1793

#3 Effective Communication - Open communication

Real stated “communication is the cement

which holds teams together”

Patient care team share their expertise, knowledge and experience

Nurses are integral to connecting the patient/ family to the team members



#3 Effective Communication by Nurses Ensure quality decisions by

seek information, process information for the physicians, individualize communication with various physicians, collaborate in the decision making, build credibility with physicians, and communicate “diplomatically”

Promote team synergy by Coordinate/mentor the team, empower lower

level team members, advocate for others, manage conflict, listen actively, foster a positive climate, manage workplace stress, and pinch hit for team members

#4 Collaboration Qualities

A relationship of two or more health care providers working together to solve patient care issues

An attempt to reach mutual agreement incorporating different perspectives to achieve mutual goals

Requires Both parties must balance the concern for others

(cooperation) with personal concerns (assertiveness)

If effectively achieved, collaborative shared decision making occurs and has been linked to improved patient outcomes


“The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime…” Babe Ruth

Teamwork

Scene of Accident 17 month old male run over by car

alarm 1817 physician on scene clears airway & gives

mouth to mouth paramedics arrive 1821

GCS 3; HR 100 O2 Sat 90%-suction airway & BMV with

100% FIO2

Teamwork Example: Anton

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GCS 3, Pupils L 3 R 2 - dysconjugate, no motor movement on arrival

VS: HR 142 BP 140 systolic Respirations assisted –no spontaneous

breathing Intubate, IVs, OG, Foley

Extensor posture right side

ED Phase 1840

Events in the Bader household at 1830 A shower A feeling A call A race to the hospital Another call to a friend A rush to the OR

Meanwhile back at MKBs Home

CT Scan Admit CT Scan Admit

ICP and PbtO2 probe in at 2030

See 1 Do 1 Teach 1 all in one moment….

PbtO2 3.5 mm Hg (low Normal >20)

MAP 51-73 ICP 25

OR Phase 1940

GCS 3, pupils 4 mm non-reactive Cerebral Hemodynamics

MAP 70 - ICP 13 = CPP 57 PbtO2 3.5

Orders Keep CPP > 55 Drain ICP < 15 mm Hg or 20 cm H20 Propofol 50 ug/kg/min

Peds ICU 2110

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MD: Orders for Brain Death Testing… MKB: So…Ya wanna give up?...

Peds ICU team assembled 2 peds ICU nurse 1 trauma nurse 1 Respiratory Therapist Neuro/Critical Care CNS – that’s me Oh…and 1 neonatologist Anton

Ventilator, ICP, LICOX, OG, Foley & 2 -24g peripheral IVs

Never Give Up… Never Surrender

Time FIO2/ MAP ICP PbtO2 Interventions

ETCO2

2133 .40/36 82 10 3.8 Increase Sedation

2141 .40/38 84 8 5.7 Drain CSF, FFP 50cc

2149 .40/39 85 9 6.3 Increase Vasopressor

0140 .50/41 90 8 13.2 RBCs 100cc

0205 .50/42 93 10 18.2

0400 .50/38 90 8 15.9 PaO2 87 -Inc FIO2

0615 .60/38 91 10 20.4 GCS 4-5-1T

PICU/SICU RNs, Neuro ICU CNS, & RT work as a team through the night…

Peds Intensivist gets report from Neonatologist ---grim prognosis

PICU RN begs Intensivist for a central line

6am: Enter the Peds Intensivist

CT Scan Post-op Day 1 CT Scan Day 1

http://thewizardofoz.warnerbros.com/movie/cmp/r-photos2.html

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CT Scan Day 1 Nay Sayers Abound….

…but the TEAM does NOT Give Up!

Trends ICP drifts up to high of 30 Pbto2 decreases in response to certain

activities and interventions

The Team learns new technology together…shared decision making occurs between all practitioners

Peds ICU: 48 hrs-7 days

Days 7 PaCO2 normalized….40-54 Seizure @ 1300

Ativan/Cerebryx bolus

Day 9: LICOX removed and wean

Day 12: ICP removed & Extubated

Day 13: Scoots up to top of bed/moving arms Plays “where’s your tummy” with mom Sits up with OT -trunk control/no neck

Day 23: Feeds self

Weaning: Days 7-23

Gymnastics at age 5

High School student

Athlete Soccer Star

ANTON Age 14

PURPOSE “Great teamwork is the only way we create the breakthroughs that define our careers” (Pat Riley)

http://thewizardofoz.warnerbros.com/movie/cmp/r-photos.html

http://thewizardofoz.warnerbros.com/movie/cmp/r-photos.html

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1995-1996 AANS publish “Guidelines for the Management of Severe Head Injury” Paradigm shift for managing the

TBI patient population

Mission Hospital recognizes a variance in practice exists

Find a Process to Improve

Organize to Improve the Process April 1997- Trauma /Neuro Services begin

process of changing practice Conduct further R.O.L. on severe TBI

Clarify the Issue Review scientific literature Review outcomes of Severe TBI population

Understand the Source of Variation Clinical Practice divergent from the guidelines

FOCUS PDCA

Select the Process to Improve Develop multidisciplinary treatment

guidelines for use in severe TBI patients

Plan/Do/Act Develop/Implement new guidelines Train personnel Educated staff on new care practice Clinical support provided on 24/7 basis

FOCUS PDCA Check: June 1998

January 1994-June 1997 37 Patients

GOS 4-5 27.03%

GOS 2-3 29.73%

GOS 1 43.24%

June 1997-June 1998 18 Patients

GOS 4-5 61%

GOS 2-3 11%

GOS 1 27%

Check

Analyzed first year processes & issues Intubation procedure in ED Timing of SjO2 placement/PA catheter Concerns regarding intraoperative

management MAP sub-optimum in OR Propofol underutilized

Increased incidence of pneumonia/ARDS Acute withdrawal signs in patients on MS

and Ativan for > 7 days

Act

Revised Clinical Guidelines Developed protocols/procedure

Rapid Sequence Intubation Morphine/Ativan withdrawal Proner

Continued ongoing support of staff at bedside

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Check 2001 Act 2001

Outcomes gathered and analyzed Outcome data consistent

New technology approved by FDA Brain Tissue Oxygen Monitor Integrate of technology into protocol Educate all staff Rewrite all TBI protocols integrating

technology Providing 24/7 support of physicians/

nurses by Neuro CNS

Case Study LT

Intro: 29 yr old female fell or jumped from slow moving vehicle. Witnesses sate she hit her head and had brief LOC Boyfriend takes pt. back to apartment Later – unable to waken her

Calls 911

Prehospital

Exam Neuro changes from GCS 1-1-1 to

combative VS 110/50 HR 72 Unable to get IV due to combativeness Blood coming from both ears Hematoma on Left Parietal area Designated trauma

ED Phase: 0210

Admitted as neurotrauma GCS fluctuates 3 to 9 to 3

PERRL at 3 mm

Trauma MD intubates patient 100% FIO2 CO2 35 mm Hg

2 Large bore IV lines 170/120 HR 98-114 RR 24

Radiology: 0240

CT Multiple skull fractures over left

parietal and left occipital area Left basilar skull fracture Diffuse cerebral edema with

obliterations of ventricles and loss of ambient cisterns

Shift left to right Bifrontal contusions

ICU Phase - Admit

Day 1: GCS 7, PERRL ICP 8-21 and CPP 63-84 PbtO2 normal range Propofol 40-80 mcg/kg/min

CO2 MAP ICP CPP PbtO2 SjO2 Interventions

36 89 20 69 54 68 CSF; Propofol

37 91 22 79 16.9 69 CSF, 100%, Pupils ∆

3 – 6 absent; Mannitol

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ICU Day 5

Pentobarb coma – full medical support

All measures exhausted ICP > 25-30 mm Hg Pupils 6 and absent To OR for bilateral craniectomy

Day 5 Postop


28 116 62 54 20.1 CSF; Pent @ 3mg/hr

28 132 67 65 16.7 81 CSF; Neo↓; MD talks

to family poor prog.

29 126 65 61 13.3 100 CSF; RBCs

Family decides to make patient a DNR

Say Goodbye and go home to plan funeral

ICU Day 5 – In the Heat of the Night


36 95 58 37 10.9 95 CSF; MS/Ativan dc

100%; Wean Prop off

31 90 45 45 11.5 94 CSF; Donor service

called

31 95 40 55 15 100 CSF

29 98 38 60 14.9 97 CSF

23 88 37 51 15.7 60 CSF

Day 6: A Call from the East

Do you give up when the PbtO2 rises??

CNS and Trauma Surgeon talk Trauma and Neurosurgery talk Family called back to hospital – making

funeral arrangements Family conference held with Trauma and

Neurosurgeon

26 98 47 51 22 83

Not brain dead yet

ICU Day 7

ICP increases to low 50s…challenging the team CSF draining continuously Pentobarb/MS/Ativan/Neo/Dopa Daily Bronchs


37 103 50 53 28.8 57 Vent changes

32 121 55 66 27.6 Mannitol

29 127 39 88 34.4 62 Neo decreased

29 100 31 69 28.9 58 Packed RBCs

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ICU Days 8-13

ICP Management requires all level of support

ICP ranges high 20s to 40s PbtO2 30s G/J tube placed; Trach done Rotation on Triadyne impossible due to high ICPs in 40s…Pulmonary worsens

ICU Days 8-13

ABGs pH 7.23 PaCO2 41 PaO2 73 on 100% FIO2 PC with pressure at 35; Rate 28 Inversed 2:1

Pentobarb off

Pulmonary Crisis Day 14

pH 7.22 PaCO2 48 PaO2 61

100% FIO2 Press 42 Inverse2:1

Gradient PaCO2 –ETCO2 =24

Pulmonary

10-11

10-12

Progress

Day 18: Normalized on ventilator Weaning MS/Ativan LICOX/ICP d/c

Day 24 Hydrocephalus begins – new ICP GCS 1-4-1 Pupils 4/brisk

Progress

Day 37 Weaning from ventilator Up in chair with helmet

Day 40 Unable to do VP shunt due to belly

probs

Day 84 - VP shunt placed Day 86 – to floor Day 105 – to Subacute facility

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Outcome Subacute 9 months

To ARU at 1 year Discharged home 14 months after accident

Check/Act- Results of Changing Practice: TBI Guidelines/Oxygen Monitoring Jan 1994 – Jun 1997

37 Patients* GOS 4-5 27.03% GOS 2-3 29.73% GOS 1 43.24%

Jun 1997 - Dec 2007 205 Patients**

GOS 4-5 72.5% GOS 2-3 13.5% GOS 1 14.0%

GOS: Odds ratio for the significant variable

(N=242)

Variable Odds Ratio

95% Confidence Lower Bound

95% Confidence Upper Bound

P Value

Post TBI 7.05 3.10 16 <0.001

Process Outcomes: Recognition 2000 JCAHO Codman Award

“Individually, we are one drop. Together, we are an ocean.” (Ryunosuke Satoro)

PASSION If there is no passion in your life, then have you really lived? Find your passion, whatever it may be. Become it, and let it become you and you will find great things happen FOR you, TO you and BECAUSE of you. (T. Alan Armstrong)

CASE: BE

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34 year old para 4 gravida 4 Admitted 2 weeks prior to event 34 weeks

pregnant due to intrauterine growth retardation

C-section on 12/1 delivered a 1247.4 gram (2

lbs 12 ounces) male baby

Collapses in hospital room after returning back to bed 24 hours post delivery

Clinical Presentation 12/2/09

Kyle Ervin writes in his book… Please God Let Them be Amazing

I turned back to her. I don’t know if I sensed something was wrong…whatever

the reason, I turned, and when I did, her head was laying back over the top of

the chair…I called the nurse….Her doctor came in to the room and his

demeanor changed instantly…

“WE need to get her on the bed!”

I helped him and the nurse lift my wife’s limp body onto the hospital bed…

“Call the code”…said the doctor

The dread built up inside me as the reality of what was happening became

clearer. I heard the words “Begin CPR”. Those words sparked a fear so

intense, so primal, that it exploded within me, shattering the dam of denial and

washing through every part of my being…It was Wednesday. It was supposed

to be a day of celebration… I was standing in the hallway, powerless…

I prayed…Please God, let them be amazing…” (Pages 38-39)

PEA arrest Cyanotic from chest up CPR initiated immediately x 95 minutes

CPR continues in CT scan Large PE in proximal portions of

bilateral pulmonary arteries

CPR continues into the OR

Cardiac Arrest 1420

CPR continues into the OR at 1506 Chest opened through sternal incision

On cardiopulmonary bypass: 1555

Cardiac Arrest 1420

1607: Aorta Cross clamped Surgeon removes multiple clots

Largest clot 10 cm x 1.7cm Multiple clots from 0.8 to 10 cm

1650: Aortic cross clamp removed

43 minutes total

1658: Off bypass 63 minutes

Cardiac Arrest 1420 In OR… A nursing team that has the PASSION

to make a difference…they place…

THE CALL Anyone can dabble, but once you've made that commitment, your blood has that particular thing in it, and it's very hard for people to stop you.

(Bill Cosby)

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Getting the Equipment Pad based system and machine

borrowed from Mission/Probe St Jude’s

Protocol and Order set from Mission

Collaborative Team Key Players

Nurses and Physicians @ Anaheim Administrative Support @ both hospitals APNs from Mission Hospital

ICU Phase: Beginning Hypothermia

2000 admit to ICU GCS 3 with pupils 8 mm bilateral & fixed VS: BP 105/64 HR 70 R 14 (V) T 99.8 F

Induction of hypothermia at 2200 Iced saline 30 cc/kg (2 liters)

Drops temperature from 37.2 to 35.6 degrees C

Pad system applied and started Hit target of 33 degrees C at 0100

ICU Phase: Post Arrest

14 Phone Calls during the night…and the dream at dawn!

“There are only two options regarding commitment. You're either in or out. There's no such thing as a life in-between.” (Pat Riley)

Maintenance Pupils begin sluggishly reacting to light at 0500 12/3

33 degrees

Rewarm 1900 12/3 to 2000 12/4 No bleeding complications/VS stable

ICU Phase: Hypothermia

Diagnostics: CT scan of Brain 12/5 Neurology Consult

Suspect hypoxic encephalopathy status post prolonged resuscitation

EEG 12/7: Severely abnormal EEG with widespread

delta activity seen in both hemispheres associated with both sharp and spike waveforms

EEG compatible with extensive bihemispheric cortical and subcortical dysfunction of an apparent encephalopathic nature

Electrocortical irritability suggested by frequent sharp and spike forms

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In Coma

Kyle Ervin writes

“I was sailing through treacherous waters…being met by fierce winds and

fiercer waves, rogue waves that would crash over my bow, flooding me, trying

to pull me under…

Why me? Why are you trying to drown me by taking from me my lover, my

best friend, my teammate? Why would you take her? Why would you leave in

her place this profound emptiness that I fall into without warning?”

Life is not only relentless. It is full of surprises…God…were you trying to teach

me something…’Cause screw you’…

I was angry with God again…And in the next breath I was bargaining with

him…The pulmonary embolism did not just take my wife from me…it took the

one person that made me a whole and complete being. Without her I am lost. I

was broken. I was less than I was…” Page 125

Medications weaned Patient demonstrates evidence of

seizures start on 12/4 and continue x 7 days

ICU Phase: 48-96 hours

In Coma

I arrived at the hospital a little later in the morning…the on-call neurologist had

already rounded…I learned the Murphy’s law of having a family member in

critical condition…no matter how many hours you spend at the bedside, you

will always miss the doctor…

The nurses were kind enough to reach the neurologist by phone…He laid it on

the line for me… “

Your wife’s EEG is showing signs of seizures. There are three

possible outcomes…One, she could die; two, things could stay the

same (persistent vegetative state), or three, miraculous

recovery…I am honestly doubtful of the third option…”

This news crushed me again… The weight of this information pushed in on me

from all sides…walking down the hallway…anger welled in my eyes…. “God,

either take her or heal her, but none of this middle-of-the-road bullshit!”

(Page 155)

Silence is medication for sorrow (Arab Proverb quotes )

Silence….for 3 weeks…

During that time… Kyle writes on 12/9

I’ve learned that Catholics pray the rosary…the rosary brings comfort and

solace when times are difficult…for me, the poster child of ADD, the rosary is

a special kind of torture—20-30 minutes of repetitive droning…On this night,

Brynn’s friends had asked a member of her church to come and pray…she

had some track record with healing…

“Lets all join hands and pray”…said the lady

“I wanted to say…that’s ok, you can leave me out…”

but knowing I was stuck, we all held hands in a circle and prayed…”

I put my hand on Brynn’s head…I chucked away my cynicism…I figured I

would have a few words with God myself…I opened myself up completely…

I reached out to that greatness, that positive energy…that hugeness I call

God…I opened myself completely….And for a moment, I believed that HIS

energy was passing through me, into her brain…Call it chi or life force or the

Holy Spirit… All I knew is that I was willing to try anything to save my wife’s

life…” (Page 170)

12/11-25 Moving non-purposefully and began to

open her eyes spontaneously

Smiling and laughing 12/21

Weaned from ventilator 12/23

Progressing through Coma

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The Call – Christmas the Day After

Never Give Up. There is no such thing as an ending.

Just a new Beginning.

12/28 Stands at bedside with

physical therapy Speaks to her husband through

passy-muir valve Says “cold” and “mom”

12/30 Tells nurse how she met her

husband in college Brings baby to bedside Able to stroke baby’s face Transferred to acute rehab Baby discharged home from

hospital

Waking Up

12/30 Walking with assistance “chatting up a storm” Cannot remember conversations

1/5 Eating oatmeal Strengthening

1/19 Home with baby

Acute Rehab One Year Later Kyle writes…

“Without divine intervention-without the exact

right people in the exact right place, at the

exact right time—medical science would not

have had its chance…Here is the simple fact

of the matter- I don’t care who gets the credit

for the ‘why’. I only care that God gets the

credit for the how”… (Page 192)

Brynn’s

Nursing

Team

Brynn’s

&

Family

YOUR CHARGE! “When work, commitment, and pleasure all become one and you reach that deep well where passion lives, nothing is impossible.” (FranÁois de la Rochefoucauld)

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