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Experts advocate small, practical programs
How well is your ICU measuring up? The question is on everyone’s mind. But when applying performance-measurement tools to critical care, getting answers can be elusive and frustrating, according to many nursing researchers.
"ICUs are undergoing enormous change. Yet, there isn’t a lot out there for them to use effectively," says Gayle Whitman, RN, PhD, a critical care nurse and director of the Health Care Outcomes Center at the University of Pittsburgh School of Nursing.
A lack of research tools that are easily adaptable to critical care units (CCUs) is only one problem. Too little time, too few resources, and poor confidence and expertise in the research process are additional factors facing nursing administrators, experts say.
Getting management’s support and the sizable cost and staff time involved in developing effective programs also can be daunting, especially for smaller hospitals.
But Whitman and other veteran researchers argue that CCUs can still investigate their own track record without necessarily undertaking long, arduous internal research.
Much of what has already been done has been published and is available in the medical literature, says Lisa J. Massarweh, RN, MSN, CCRN, an assistant professor of nursing at Kent State University in Ashtabula, OH.
Although the statement risks repeating what’s obvious, it’s surprising that most hospitals fail to exploit those resources, experts say.
Administrators can use what’s been published as a template for conducting their own unit’s research. The effort is particularly useful when assessing organizational performance involving factors such as length of stay (LOS).
That’s because the data involved are readily accessible and more clearly defined than the clinical patient data, Whitman argues.
Research can help determine outcomes
Organizational research can yield important performance-related facts, such as the department’s average LOS in determining positive, targeted outcomes. It can also help explain the reasons for discharge delays and the effectiveness of current nurse discharge planning.
Indeed, Massarweh conducted her own assessment of nursing unit performance characteristics a few years ago in a study of three CCUs within the same hospital. The effort was part of her graduate work in nursing at Gannon University in Erie, PA.
The study used previously published research as the basis for assessing key nursing characteristics such as leadership, intra-unit communication, coordination, and problem solving. Clinical team cohesion and perceived unit effectiveness completed the six studied parameters.1
Massarweh used the parameters in a survey of the three CCUs to assess how nurses felt about organizational processes and managerial practices. Using the template made the work a lot easier, she says.
The template came from a groundbreaking national study of ICU nursing conducted in the early 1990s.2
The call by nursing leaders to rally around research has never been greater. "Where evidence-based practice is available, it must be universally disseminated and applied so that all patients may benefit," exclaimed Grif Alspach, RN EdD, the editor of Critical Care Nurse, in a recent editorial.3
Yet, faced with those pressures, CCUs, as a whole, don’t have a strong record on internal research, Whitman notes. Much of it is spotty and the findings are often conflicting, Massarweh adds.
Yet, the CCU is a setting that is continually evolving, Whitman says.
The latest trend study conducted by the American Association of Critical Care Nurses (AACN) in Aliso Viejo, CA, finds compelling evidence that critical care nursing is indeed evolving.4
Evidence of drastic change
The study, which AACN conducts annually, found several common themes this year affecting ICUs nationwide, among them the growing effects of technology and managed care.
Added to the list are concerns about patient psychosocial factors, and ethical and legal issues directly affecting nurses and patients. (For specifics on the AACN study, see related article, above.)
While professional groups such as ACCN are pushing for better nurse training and higher certification standards to address those changes, there’s been little in the way of formal intelligence-gathering available to support those initiatives, Whitman observes.
In assessing mortality and morbidity, the best-known and most widely cited tool in the ICU has been the Acute Physiology and Chronic Health Evaluation (APACHE), a prognostic scoring system now in its third generation.
But APACHE III isn’t perfect, and although it helps as an aggregate scoring system it doesn’t necessarily reflect individual CCU conditions, observes Lynn Kelso, RN, MSN, CCRN, an assistant professor of nursing at the University of Kentucky in Lexington.
Other similar scoring systems have included the Simplified Acute Physiology Score II, and the Mortality Prediction Model II. But nothing like them has evolved in measuring organizational performance in the ICU, Whitman observes.
In the absence of anything similar in organizational research, it appears nursing and finance departments have used and interpreted indicators such as length of stay, nursing hours per patientday, and cost to discharge in different ways, nurses say.
The American Hospital Association in Chicago and a handful of consultants and accounting firms routinely publish national hospital utilization benchmarks. But they fail to focus specifically on ICUs, Whitman notes.
"For the hospital, these data are quite useful. But they lose a lot of their specificity when they get down to the ICU level," Whitman says.
And "not one consistent method is currently used to assess quality among and within critical care units (CCUs)," Massarweh says.
In her own research, Massarweh found that nurses from the three CCUs that were studied held markedly different views toward their own unit’s work. She also found that units vary widely among themselves, even within the same institution.
Fundamental research works
As a result, it was difficult to make broad generalizations about nursing quality for a whole hospital. But it is feasible to study each unit separately, Massarweh concluded.
Similarly, as a nurse manager, Whitman investigated the reasons for delayed discharges of certain cases from her unit. At the time, the ICU’s LOS was reported to be as much as 30% to 40% higher for certain post-operative cardiac cases.
A large group of patients was exceeding the average one-day stay in the ICU and five days in a step-down common to most cases.
Simply by reviewing the medical records within a selected window of time, Whitman says she isolated 30 patients who were responsible for increasing the unit’s average LOS.
The reason, she found, was that the patients were all suffering from post-op atrial fibrillation, indicated by dysrythmia and minor respiratory complications. However, Whitman never suspected that the problem lay in the nursing care.
A little investigative work mulling further through the files determined that physicians and nurses were applying a wide range of different criteria in administering the required loading dose of digoxin for those cases.
The medication ordering and dosing variability all fell within a certain parameter, but were wide enough to cause marked differences in LOS, Whitman stated. Some physicians would wait to use a second drug often up to 48 hours before cardioverting the patient. Others waited much less time. Once discovered, clinicians went to work to establish a set, agreed-upon protocol for proper dosing intervals prior to cardioverting.
The incident proved that quality research doesn’t have to be complex or all encompassing, Whitman notes. Not always, but "sometimes, a simple pencil-and-paper task can yield good answers," she says.
What’s important is that you have sound ideas concerning what you are looking for and are realistic about the resources you’ll need to find it, says Kelso.
Sometimes, simplicity is best
Although often limited in usefulness to a CCU, national associations can help scratch the surface when studying areas, such as effective pain management and parenteral feeding techniques. The Internet is a vital resource for those initial investigations, advocates say.
"Look for the best that’s out there. It doesn’t hurt to try to emulate others. More often than not, they’re happy to share information with you," Kelso concludes.
1. Massarweh LJ. TQM in critical care. Nurse Manage 1998; 29:48F-48I.
2. Shortell S, et al. Continuously improving patient care: Practical lessons and an assessment tool from the National ICU Study. Quality Review Bulletin 1992; 18:134-140.
3. Alspach G. When the evidence’ in evidence-based practice is ignored: A time for advocacy. Crit Care Nurse 1999; 19:10-14.
4. Biel M, Eastwood J, Muenzen P, et al. Evolving trends in critical care nursing practice: Results of a certification role delineation study. Am J Crit Care 1999; 8:285-290.