What can a Clinical Nurse Leader do for your critical care nursing unit? Plenty! Consider this new nursing role as one that can improve patient outcomes and increase satisfaction for both clients and staff. Successful microsystems begin with empowering patients, families and front line nurses.

1. Ann Deerhake, MS, RN, CNL, CCRN
CNL USF Conference Logo 2011

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

3.  Is the CNL role new to this facility? This
setting?
 What types of leadership and staff are
present in this setting?
 What effect will this
setting have on the CNL
duties and responsibilities?

4.  Perform advanced patient assessments
 Plan care/Change care
 Empower frontline nurses
 Partner with the interdisciplinary team
 Grow clinically

5.  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

6.  Empower the patient
 Assist with continuity of care
 Promote evidence-based practice
 Build collaborative relationships
 Speak up!

7.  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

9.  Know when to lead, when to follow
 Develop personal competencies
 Find a common purpose
 Identify and resolve barriers
 Set your team apart from the rest

10.  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

11.  Identify patient safety issues/risk
 Develop realistic action plans
 Promote systems thinking
 Encourage others to get involved

12.  Identify patient safety issues/risk
focusing on reducing nosocomial infection
 Promote systems thinking
in addition to advanced critical thinking
 Develop realistic action plans
utilizing frontline staff knowledge
 Encourage others to get involved
as health promotion and safety officers

13.  Encourage horizontal leadership
 Meet personal CNL goals
 Help other nurses reach their goals
 Elevate the profession of nursing

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

16.  Share what you know “knowledge transfer”
 Be a coach
 Research and disseminate
 Formally present

17.  Share what you know “knowledge transfer”
it goes both ways!
 Be a coach and an issue resolver
in critical situations
 Research and disseminate information
on the fly and methodically planned
 Formally present
as an ICU nurse and educator

18.  Improve communication
 Reduce errors
 Increase patient/family satisfaction
 Increase recruitment/retention
 Disseminate information using variety of
methods

19.  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

20.  Performance 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.

22. 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

23. 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

24. 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

26. Patterns
 Risk of EVD infection
 No protocol for dressing changes
FROM JULY 2008-JULY 2009
20% INCREASE IN EVD
INFECTIONS!
(NOSOCOMIAL VENTRICULITIS)

27.  Minimal 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

28.  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

29.  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

30. 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
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

31.  Controlled 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
 Small participant number (n=26)
 Single facility study

32.  No further CSF infections after daily dressing
change instituted (July 2009-July 2010)
 Reduced rate of nosocomial ventriculitis
from 54% to 0%
 Equates to a savings of $44,972
 Potentially decreased LOS by 127 days
 Increased patient, family and nurse
satisfaction

33.  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

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