1

Creative Coaching & Educational Strategies to Develop Critical

Thinking SkillsPart II:

Critical Thinking & Evidenced Based Practice Projects

Critical Thinking Habitsfor EBP projects

� Confidence

� Contextual Perspective

� Creativity

� Flexibility

� Inquisitiveness

� Intellectual Integrity

� Intuition

� Open-Mindedness

� Perseverance

� Reflection

Source: Rubenfeld M, Scheffer B. 2006 Critical Thinking Tactics for Nurses

2003Beginning the Journey towards...

Improving Patient Outcomes

The Bedside Nurse & Research

� Gladys M Campbell, RN, MSN• Past AACN President

• Assistant Administrator of Nursing

� Granger, B, Chulay, M 1999 Research Strategies for Clinicians. Appleton & Lange, Stanford, CT

5C Focus GroupGoals:

� Explore ideas for clinical questions on 5C to improve patient outcomes

� Pick one clinical question to work on as a project.� Clinical question will either be developed into a research

question and project or developed into a performance improvement project.

� The project will be a clinical issue not a process issue.� Involve most of 5C staff in the project to increase

ownership in improving patient outcomes.� Pick a clinical topic that can be a short project (6 months

or less) - to keep momentum going and show success.� To promote teamwork, morale, and professionalism with

5C staff � Possibly use other clinical questions in PI team� Develop a project that can be used for JCAHO to show our

commitment to improving patient outcomes.

PlanWeeks 1 - 3� Brainstorm for ideas:� Use focus groups to brainstorm for ideas.� Provide lunch for staff and have brainstorming from 11 -

13, 18 - 20, and sometime on night shift on a few different days. Staff can come as they wish and participate. This should involve most of staff.

� Provide post - it notes in easy access clinical locations to jot down ideas.

Week 4� Prioritize clinical questions and narrow down to one we

want to work on. Time frame: Week 5� Decide how to approach clinical question to improve

patient outcomes - ie research study or performance improvement project

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Week 6, 7, 8� Protocol development� Develop forms� Review literature

Week 9 - 10 � IRB submission if needed

Week 11� Collect data

Week______� Analysis of data� Implementation of new protocols, if needed� Publish results

5C Focus GroupPreceptors

Insanity is...

�Doing what you have always done and…..

� Expecting different results

It’s always…

� “Sit”, “Stay”, “Heel” ---

� Never

� “Think” “Innovate” “Be Yourself”

Let’s go Beyond Competence

Beginning the Journey

3

WHY???? Who is the best person to decide patient care?

You,the nurse!

� WHY?• You have a keen grasp on the needs of patients

• You know what complications frequently occur?

• You are creative

• You process problems & generate solutions

• YOU DO THIS EVERY DAY!

Coming soon to 5C...The Journey towardsImproving Patient Outcomes

� What is the journey?

� Finding a clinical question and making a difference in patient outcomes

� Start asking the question WHY? WHY? WHY?� Why Do we do what we do? � Why Do we do it that way? � There has to be a better way to do this!� Why do we always see this complication?� Why do we do different things for the same type of pt?

Stay tuned for more details……. Get involved!

Questions to ask to find a clinical EBP to improve patient outcomes� Start asking the question WHY?

WHY? WHY?� Why Do we do what we do? � Why Do we do it that way? � There has to be a better way to do this!� Why do we always see this complication?� Why do we do different things for the

same type of pt?

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5C Journey towards Improving Patient outcomes

You are now an official STICK member on the 5C Journey

� Spontaneous Thoughts

� Thinking out of your Box

� Innovative Ideas

� Curiosity

� Keen perception of patient outcomes

5C STICK ProjectBrainstorming IdeasJan 24 - 30, 2003

� Question: � From a clinical perspective, what is the

most important thing that prevents 5C patients from achieving optimal outcomes?

Brainstorming top topics

� Pain Control� Family Attitudes� Patient Attitudes� Activity – not being achieved� Respiratory complications� High risk patients – how do we treat differently� Compliance and readmissions in Heart Failure

patients� Discharges� Plus 25 other ideas

Pain

� When patients in Pain, they may not have the best attitude

� Thoracotomy pt have more pain and more chest tubes for longer periods of time

� Inadequate pain management� If in pain, don't move� Elderly afraid to ask for pain meds -- think will

become addicted

Family Attitude� Family Attitude/overbearing -- Can make a big difference for the

patient� No family support - family doesn't come� Family is upset that you are walking pt - too much too soon. � Family doesn't understand what is good for the patient� Don't understand set backs -- need to explain� Family doesn't push patients� Family doesn't want pt to go home - think it is too soon� Family "overprotective"� Sit on bed - come in with colds - what are they bringing in to the pt??� Food all over the room� Family takes over the room� Family doesn't want you to push pt or they don't want to push pt� Overprotective family� Family expectations - If family negative, can't help pt� Need buy in from family & pt about pt care

Patient Attitude

� Patients have unrealistic expectations of their illness & care

� Need positive attitude� Staff also needs positive attitude about pt - even if

difficult/challenging pt� If negative attitude - don't do well� MD communication with patients - don't know what to

expect - listen more if comes from physician.� Not wanting to do things that make them better� Don't know or understand expectations� Need buy in about care

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Respiratory

� IS

� Not getting off oxygen

� Respiratory problems

� Oxygenation

Activity� Activity is significant percent� Not getting up & walking or delayed - neuro changes postop� Staff not taking time to walk patients� Activity gets pushed to the side if busy with other priorities� Walking takes 100% focus� High turnover of patients can impact activity� Write goals for the day on the board -- activity -- tell pt what's expected -- get them

motivated -- help give pt pep/ motivation talk� Set time for walks -- nurse-patient� Not enough manpower & people to do it� Pt wait for staff to do walks� HF don't want to do activity as they are SOB� Don't want to move� Staff doesn't stress importance of activity� If in pain, don't move� Not turning patients so get bed sores� Don't know activity wasn't met on other shift -- get too far into shift until know what to

focus on� Improvement of Team work between RNs & ancillary staff to accomplish goals� Don't push patient � Think time to go to bed at 7 pm so don't want to walk� Maybe do 6 am walk?� Probably need more than 3 walks per day --- but don't even get three walks in per day

High Risk Patients

� Do we treat patients as high risk vs low risk?� Don't have different plan of care� Need a different plan of care starting pre op� Don't alter for baseline status� MI pt not waiting until heart muscle healed to go to OH� Preop CABG - what do we do differently for MI - esp if

waiting 2 days� Don't treat CABG + preop/periop MI any different than

just CABG� Elderly� High risk patients don't do well

HF Patients

� Can't understand why they get fluid overloaded - can't understand why they are "frequent flyers"

� Compliance

� Teaching not consistently done

� Daily weights not always done

� Timely discharges� High turnover of patients � Differing opinions between MDs� Lack of communication between MDs, family & nurses - impacts LOS� Carepath --� Set backs� Social Issues� Compliance with medications -- no financial resources� Wet boards� Diet education� Poor telemetry readings� Nutrition� Oral care/ nose care not consistently done --- noses dry from oxygen� Ear sores from nasal prongs� Infection at IV sites� Incision/wound care� Infection� High acuity of patients on 5C so don't always get the care they need as it becomes a lower

priority � Placement of patients� 12 hour shifts -- have many patients during shift making it difficult to get things done.� Angio/PTCA/stent patient� Assignments are spread out -- waste lots of time running � Arterial lines -- do we need a setup of going to D/C soon� Difficulty sleeping� Overwhelmed with so many things to do so can't get all things done� No CNA to CNA report� CABG pt come out of CVICU too soon� RNs uncomfortable taking care of noncardiac pt -- we take everything� More public education about S & S MI so come in sooner� Time constraints for staff -- important things, like activity, get lower priority� Not having a BM

5C Next PhaseBrainstorming: Activity

� “What is the most important thing we can do to increase Activity in the 5C Patients?”

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Walk to Recovery

� Chairs for Meals

� Scheduled Walks• 1st Walk: between 06 – 08

• 2nd Walk: before lunch

• 3rd Walk: before 1330

• 4th Walk: before dinner

• 5th Walk: after dinner

• 6th Walk: before bed

Walk to RecoveryWalk to Recovery

� Walking from your room, around the

desk and back is 150 feet

� Walking from your room, around the

desk and back is 150 feet

5C STICK Project - 2003Percentange of Patients in the Chair for Meals

0

10

20

30

40

50

60

70

80

90

March 24th May 14th May 21st June 27th July 8th August 12th October 2nd

Per

cent

age

Chair %

Data collected by 5C Education CouncilComplied by CHerrmann, APN

= Good

� Chair for Meals increased from 18% to 79%

� Activity increased from 33% to 60%

5C STICK Project -2003Percentage of 5C Patients Achieving Prescribed Activit y

0

10

20

30

40

50

60

70

80

90

100

March 24th May 14th May 21st June 27th July 8th August 12th October 2nd

Date

Per

cent

age

Activity %

= Good

Continuing the EBP Journey

� Monthly unit specific PI team meetings• CVICU

• 5C Telemetry

2007 Introduction to Unit Based Evidenced-Based Clinical

Practice Councils

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Evidenced-Based Practice

• What do you think Evidenced-Based Practice Means?– Brainstorm definitions on flip chart

Evidenced-Based Practice Definition According to the

Literature• Integration of best research evidence with

clinical expertise and patient values (Sackett et al, 2000)

• Process of using current evidence to guide practice and clinical decision making

OR

Council Exercise

• Think of practices that are currently in place on your unit– Of those practices brainstorm a list on the

flipchart those that you think are currently based on the evidence

– After brainstorming, rank those practices 1-5 (5 being fully integrated into practice)

– Rank them again from 1-5 (5 being everyone understands the evidence behind the practice)

Methodist Model of Evidenced-Based Practice

Note: This model adopted from University of Iowa Hospitals

Example of MMCI project using Existing Evidence (Adopted Practice)

• Project: Establish Urgent Assessment Team• Review of Evidence Findings

– Literature search found that “rapid response teams” improved clinical outcomes and reduced mortality

• Questions asked– Is this a priority for MMCI?

• Yes

– Can this EBP be fully implemented at the unit level?• Yes, we have the expertise and coverage to establish 24/7

coverage

Example of MMCI project using Existing Evidence (Adopted Practice)

• Results since UAT inception

– Steady increase of UAT calls by nursing staff

• ---% increase in calls almost tripledFrom an average of 7 calls to an average of 18

– Decline in Code Blue and Deaths

• ---% decline in Code Blues 43% decrease in code blues from an average of 10/month to a decrease of 7/month

• ---% decline in Death rate at MMCI 31% decrease in deaths from an average of 38/month to a decrease of 29/month

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Example of MMCI project using Existing Evidence (Adopted Practice)

• Project: Use of Ventilator Bundles in the ICU • Review of Evidence Findings

– The Evidence is clear and convincing that if the following key interventions are used routinely in the care of ventilator dependent patients the incidence of Ventilator Associated Pneumonia is decreased

• Vent standard of care

• HOB elevated 30 degrees

• Oral care every two hours

• Brush teeth BID (10 - 22)

• Deep oralpharyngeal suctioning every six hours

Example of MMCI project using Existing Evidence (Adopted Practice)

• Ventilator Bundles.• Questions asked

– Is this a priority for MMCI?

• Yes, MMCI Ventilator Pneumonia Rate is high

– Can this EBP be fully implemented at the unit level?• Yes, the Intensivist Team is willing and eager to take on as a

Evidenced-based project

Example of MMCI project using Existing Evidence (Adopted Practice)

• Results– Outstanding results!!!

• Zero cases of Ventilator Pneumonia for >16 months

• Overall mortality in the ICU declined by 25%

Example of MMCI project using Existing Evidence

(Practice not adopted)• Project: pH Testing for NG Placement• Review of Evidence Findings

– There are several well designed nursing studies that demonstrate that if the pH is correctly measured that gastric placement can be assured. This implies that the evidence is good.

• Questions asked– Is this a priority for MMCI?

• Yes– Can this EBP be fully implemented at the unit level?

• Is there evidence from other hospitals?• Yes, but what was the outcome?

Example of MMCI project using existing evidence (not adopted)

• The University of Iowa implemented an evidence-based project on a unit to test if pH testing could be used to check NG tube placement as auscultation has no evidence that it is a reliable method to check tube placement.

• Results demonstrated that with feedings, it was difficult to obtain an adequate sample to test, staff found the process difficult, and patients’ feedings were held to try and obtain a good sample.

Example of MMCI project using existing evidence (not adopted)

• Because of the difficulty of implementation, staff dissatisfaction, and disruption of patient feedings, the practice was not adopted.

• So, what was implemented at Methodist to check tube placement?– Marking feeding tubes, noting cm marking, noting

color of aspirate, and checking for coiling in the oral cavity. This was based on nursing studies using methods other than pH testing to check tube placement.

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So what’s up with the “Pink Panther” ?

• The pink panther pictures is the logo that MMCI uses to relate to our evidenced-based journey

Next Steps

• Brainstorm a list on the flip chart of possible topics that might be applicable for your floor’s population to examine the evidence…..

• Ask your peers to check mark which ones of those they might be interested in...

Next Steps

• Housewide monthly PI /EBP Councils

• Housewide monthly research council

• Each unit monthly PI/EBP councils– CVICU/ICU

– 5C Cardiac Telemetry

– Cath lab

Cardiac PI/EBP CouncilsBrainstorming

• Think of practices that are currently in place on your unit

• What interventions do you use in practice?– Hemodynamic monitoring– Cardiac output measurements– Incision care– Turning– IV site care

• What is the knowledge base for the practices?

• How can research improve/influence these interventions?

Brainstorming: Inquiring Minds Want to Know

• Start asking the question WHY? WHY? WHY?

• Why Do we do what we do?• Why Do we do it that way?• There has to be a better way to do this!• Why do we always see this complication?• Why do we do different things for the same type

of pt?

Brainstorming

• What are the weak areas on your unit?• What are your frustrations?

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Sample Cardiac EBPs

• Critical Care Insulin Protocol

• Activity Protocol for ICU

• Sepsis• Promoting Sleep• Falls• Wounds

• Decrease hemotomas• Improving

communication for delays in cath lab start times

• Medication Administration Safety

• Alarm Fatigue• PCI times for STEMI

Literature Review

“Journal Club”

Literature Review

“Journal Club”

2006 - 2009

Coaching Evidenced Based Practice Projects with Individual Staff RNs

by Methodist Tier Project Committee Members

� Apply with clinical question

� Paid 8 hours per month to work on project

� Assigned to CNS as mentor

Awareness of Central Illinois Women about Heart Disease compared to2006 American Heart Association

National Study

Lori K Young RN-CMentor: Cheryl D Herrmann APN, CCRN, CCNS-CSC/CMC

September 2008

Purpose

To evaluate Central Illinois women’s awareness, knowledge, and perceptions, related to Heart Diseas e as compared to the 2006 American Heart Association National Study. 1

Source: Christian A, Rosamond W, White A et al. Nine-year Trends and Racial and Ethnic Disparities in Women’s Awareness of Heart Disease and Stroke: An American Heart Association National Study. J of Woman’s Health 2007, 16(1):68- 81.

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Preceived Leading Cause of Death Among Central IL Women

61

21

9

5

1 1 1 10

10

20

30

40

50

60

70

Heart D

isease

/Hear

t Atta

ck

Breast

Cance

r

Cancer -

gen

eral

Do Not

Kno

w

Diabe

tes

Stroke

Obesit

y

Other

Dise

ase

Per

cent

Heart Disease/Heart Attack

Breast Cancer

Cancer - general

Do Not Know

Diabetes

Stroke

Obesity

Other Disease

n= 129

Central Illinois women’s awareness of heart disease as the leading cause of death among women was 61%, slightly higher than the national study of 57%

Awareness Of Central IL Women of the Symbols for Heart Disease & Breast Cancer

49

96

0

20

40

60

80

100

Red Dress Pink Ribbon

Per

cent

Red Dress

Pink Ribbon

n= 120

Only 49% of women surveyed were aware of the Red Dress Symbol for Heart Disease96% were aware of the Pink Ribbon Symbol for Breast Cancer

Critical Thinking for

Troponin Levels

When to call

When not to callJamie Dooley, RN, BSN, PCCN

• Have you been frustrated that

hospital policy requires you to

call all critical troponin levels…

and then the cardiologist is

upset that you woke him up in

the middle of the night?

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The Solution!!!

• A Critical thinking algorithm to

help you determine when to call

the MD, when not to call, and

what you need to document.

Case #1

• Mr. Adams is a 49 year-old male who was admitted to 5C on the shift before you. His troponin level in the ED prior to coming to your floor was 2.64. Dr. Eedar saw him upon arrival to the floor and is planning to take him to the cath lab in the AM. Dr. Eedar’s H&P reflect the troponin level of 2.64 & NSTEMI.

• It is now 0200 and lab has just called to notify you Mr. Adam’s troponin level is now 5.64.

• Do you call the 5.64 Troponin?

No need to call

Document in SBAR:

MD expecting elevated results

• This case

illustrated a

subsequent

critical troponin

level going up

and the patient

has a

documented

MI/elevated

troponin.Is it goingdown?

Subsequent Critical Troponin

Is it goingup?

Documented

MI/elevated

troponin? (lookin the H & P

Progress notes,

etc.

No need to call

Document: MD

expecting elevated

results

Yes

Yes

No

Yes

Case #2

• Mrs. Beta is a 74 year-old direct admit to CVICU from Cottage hospital. Before she left Cottage her troponin level was found to be 1.56. Lab has just reported her second troponin level to be 12.96. The nurse from Cottage relayed to you that the ED Physician consulted and talked with Dr. Letap but Dr. Letap has not been in to see the patient yet.

• Do you call the 12.96 Troponin?

Call the MD within 30 minutes

Document in SBAR:

MD notified of critical Troponin

• This case

illustrated a

subsequent

critical

troponin level

going up and

the troponin

level not

documented

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2010

Coaching Evidenced Based Practice Projects with Individual Staff RNs

by Methodist Tier Project Committee Members

EBP training curriculum

� Identifying a clinical problem

� Reviewing the literature

� Synthesizing the results of the literature search

� Developing a plan for a project

� Implementing and evaluating the project

January Class

� Overview of EBP Tier program and requirements

� Introduction to EBP� Levels of Evidence� EBP models

� What is a researchable problem? � How to write an EBP question� Development of EBP question for project� How to conduct a literature search � Key concepts and steps in Qualitative and Quantitative Research

February Class

� Research Designs

� Research Reviews: meta-analysis and narrative or systematic reviews

� Types of Quantitative and Qualitative Studies

� Introduction into Research Critique: Bring your articles

April Class

� Reading and Critiquing Research: Bring all studies

� Review sampling, methods, and data analysis

� Ethics in Research

June Class

� Completion of the literature review: Table due

� How to summarize the literature and develop practice implementations

� Use of frameworks in research

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August Class

� Recommendations for practice change and how to implement

� Use of change champions and support staff

October Class

� Implementation of EBP project

� Data Collection for EBP project

� How to evaluate outcomes of implementation

Evidenced Based Practice

“An Introduction to Research”January 20, 2010

Research Made Really Simple!

by Methodist Tier Project Committee Members

When did nursing research start?

� Yes…. It started with Florence (Flo)

� Notes on Nursing in 1859: Nightingale describes her early interest in environmental factors that promote physical and emotional well-being.

Coaching Evidenced Based Practice in the Classroom

On what evidence do you base the information you teach?

Self Assessment:Are you promoting EBP in your teaching plan?

• Am I handing down information or helping students SEEK knowledge?

• How old is the information I am using?• How many times do I use the word evidence or

EBP?• Have I searched for the latest evidence on this

topic?• If I searched, how did I evaluate the evidence I

found?• Do any of my course objectives address EBP and

thinking?Source: Rubenfeld M, Scheffer B. 2010 Critical Thinking Tactics for Nurses, 2nd Ed.

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ACC/AHA 2007 STEMI Guidelines Focused Update

Class III

Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administeredSINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Class IIb

Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class IIa

Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class I

Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Applying Classification of Recommendations and Level of Evidence

Level C: Recommendation based on expert opinion, case studies, or standard-of-care Very limited (1-2) population risk strata evaluated

Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies Limited (2-3) population risk strata evaluated

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses Multiple (3-5) population risk strata evaluated; General consistency of direction and magnitude of effect

Reprinted with permissionACC/AHA 2007 STEMI Guidelines Focused Update Slide Set ©2007, American Heart Association, Inc and American College of Cardiology, Inc

Target: Door to Balloon < 90 minutes

(Class 1, Level A)

or Door to Needle < 30 minutes

(Class 1, Level B)ACC/AHA 2007 Focused Update

Guidelines for Management of STEMI

Positive EKG

• ST elevation > O.1mV (1 mm) in at least 2 contiguous precordial leads or at least 2 adjacent limb leads (STEMI) (Class 1, Level A)

• Transient ST Elevation > 0.5 mm

• ST depression > 0.5 mm (NSTEMI)

• T wave inversion > 0.2 mV (2 mm)

• New LBBB (Class 1, Level A)

In Summary….

� EBP is the process of using current evidence to guide practice and clinical decision making.

�We need to incorporate EBP into our teaching.

Medical MissionTelo Islands, IndonesiaJuly 2009

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Adam IslandPopulation 250 peopleClinic = 57 people Health promotion = 74

“Bule Maso Kampeng Kristin”A white person has come to our village!

20 minutes to walk leisurely around this island

RicketsRickets

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PolioPolio

Mahang Island2 villages with population 120 & 112Clinic = 120 Health promotion = 164

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