IMPLEMENTING QSEN:

CHALLENGES & OPPORTUNITIES

Margaret Rowberg, DNP, APN

Jennifer Lillibridge, RN, PhD

California State University, Chico

School of Nursing

FOCUS OF PRESENTATION

Objectives Present results of faculty survey on

implementing QSEN

Discuss changes and barriers that were identified

Identify the strategies that have/can be used to train nursing faculty

SURVEY

n = 19 (35 full & part time faculty)

10 questions with fixed response or essay format

Online anonymous format using Survey Monkey

SURVEY RESULTS

Question 1 – knowledge of QSEN resources

68.4% = 13 were aware of QSEN

Question 2 – discuss resources used (only 15 answered the question)

2 faculty not aware of QSEN

staff work arounds

simulation strategies

safety & EBP materials,

reviewed KSAs

case studies

SURVEY CONTINUED

Courses where faculty are making plans for the future

Pathophysiology medical/surgical nursing course

Advanced practicum in MSN program

Simulation

Public health

Integrated theory/practicum

Leadership practicum

Fundamentals

CHALLENGES

TIME

Understanding best teaching strategies

Need more education about QSEN

Development of assignments

STRATEGIES

Picked theory & clinical leadership course as pilot

Reviewed current assignments to evaluate how and

where to incorporate QSEN competencies

Revised schedule & assignments so that each week

students would understand which competency was

the focus for that week

STRATEGIES

Include the IHI leadership modules as an assignment for the theory class

Class discussion examples – IHI forgotten team member, assignment on providing care through teamwork and collaboration (Pam Ironside), IHI human factors exercise

Incorporated a quality and safety assignment using staff workarounds (Lisa Day) as the topic into both the online theory course (paper assignment) and the on campus course (group poster assignment)

Who’s Counting Anyway? Kelly Doherty

Samantha Gove Keely Wong

California State University, Chico School of Nursing

What is the issue?

Despite multiple counts throughout surgery by operating room

personnel, foreign objects are left behind in 0.3-1 per 1,000 surgeries

(NIH, 2009). Retained surgical equipment can lead to a number of

problems, including pain, infection, obstruction, perforation, tumors,

multiple surgeries, and death. The surgeon is ultimately responsible

for preventing these occurrences, however the actual task of counting

instruments is delegated to nurses and other operating staff. Best

practice recommends that surgical counts occur before the procedure

to establish an initial count, again when new instruments are added to

the field, and lastly at wound closure. Although the potential for

retained foreign objects exists with any surgery, this risk is increased

when there are deviations from hospital policy and procedure.

What is the policy and procedure?

Counts should occur at the following times:

•At the beginning of a procedure, before the first incision

•Any time a new package of equipment is opened

•Closing a cavity within a cavity

•When a staff member is permanently relieved from the case

•A final count before the patient is closed

Items in the count:

•all pre-packaged instrument sets, cutting instruments, forceps, clamps,

retractors, needle holders, suction equipment, gauze, sponges, lap sponges,

cotton balls, and needles

•Items should be counted in the same sequence every time

Staff involved in the count:

• Counts are done audibly and viewed by two people

(one of which should be an RN)

•Verbal confirmation by the surgeon that the count is correct

(“Surgical counts”, 2011)

What was observed?

We observed that in multiple surgeries, operating room staff skipped

several different steps in the counting procedure.

•Counts were recorded on a piece of paper rather than designated

counting white board

•The final count was done and recorded while the patient was being

closed

•Two staff members were present and they both audibly confirmed the

count, but only one was visualizing the count

•Doctors did not give verbal confirmation of the final count

Why are there deviations from policy?

We informally interviewed several RNs working in the operating room.

Some of the common responses were:

•The extensive policy was repetitive

•Time restraints due to increased case load

•“Recounting of unused surgical equipment seems unnecessary when we

know we haven’t used them during the surgery”

•In laparoscopic surgeries, it is unlikely that anything is left in the patient

•“The doctor didn’t do the counting, so why does he have to acknowledge

it?”

What are the recommendations?

It is crucial that RNs and other operating room staff recognize the

importance of using hospital policy and procedures, as they are based on

best practice. Inattention to these details may lead to unintentional

patient harm.

•Auditing operative records to ensure that counts were completed and

documented correctly

•The use of radiopaque equipment to increase visibility of objects

•Conducting random “real time” to monitor compliance with the policy

•Initial and ongoing competencies to monitor knowledge and practice of

operating staff

•Have a printed copy of the policy readily available at the nurse’s station

for reference

•Base the policies and procedures on the AORN Perioperative Standards

and Recommended Practices

•Incorporate technology (RFID) into the counting process when further

research is done on the safety and efficiency

(JHACO Resources, 2011), (Swedberg, 2010), (AORN, 2011)

References

Association of periOperative Registered Nurses (AORN). (2011). Recommended practices for prevention of retained surgical items. In 2011 Perioperative Standards and Recommended Practice, (263-279). Denver, CO: AORN, Inc. Joint Commission Resources. (2011). Foreign objects retained after surgery. Retrieved from http://www.jcrinc.com/Foreign-Objects-Retained-After-Surgery National Institute of Health. (2009). Retained surgical foreign bodies: A comprehensive review of risks and preventive strategies. Retrieved from http://www.ncbi.nlm. nih.gov Undisclosed Hospital Perioperative Services Policies and Procedures. Surgical counts for sponges, needles, sharps, instruments, and miscellaneous items. Revised November, 2011. Swedberg, Claire. (2010). ORLocate RFID-Enabled system for surgical sponges and instruments gets FDA clearance. RFID Journal. Retrieved from http://www.rfid journal.com/article/view/

DON’T health care workers CLEAN their STETHOSCOPE?

Objective: To determine stethoscope

cleaning among health care workers in

clinical settings through literature reviews

and clinical observations.

Problems: Bacteria growth, lack of

policy and procedure, insufficient

cleaning and resources.

Setting: rural hospital medical surgical

units.

Population: health care workers

(physicians, nurses, respiratory

therapists and students).

Method: random observations over a

three day period in different situations

Result: zero percent cleaned.

Conclusion: no policy and procedure

in place; health care workers did not

clean stethoscopes between use.

Clinical Observations:

Study 1: Prevalence of MRSA on the Stethoscopes of Emergency

Medical Services Providers

Setting: urban tertiary care center with 80,000 patients per year.

Population: Emergency medical service providers.

Purpose: to evaluate for prevalence of MRSA .

Method: observational cohort study of 50 stethoscopes. Diaphragms were

swabbed and cultured. Questioners given to state when last cleaned

stethoscopes; the responses were categorized into six categories.

Results: MRSA found on diaphragms. Increased cleaning frequency was

related to decreasing bacterial growth. (Merlin, Wong, Pryor, Rynn, Marques-Baptista, Perritt, et al., 2008)

Conclusion: Normal flora and pathogenic bacteria can

be transmitted to patients through the use of

stethoscopes. Increased frequency of cleaning is

related to the reduction of bacteria colonization.

Implications and Recommendations:

•Easy access to alcohol based disinfectants

•Emphasize and educate stethoscope cleaning

• Establish policy and procedure

•Stethoscope cleaning = hand washing!!!

Dao Lao, Gaujah Moua, Mao Chong Lee

Types of Bactria Found on Stethoscopes

Study 3: Bacterialogical Assessment of Stethoscopes

used by Medical Students in Nigeria: Implications for

Nosocomial Infection Control

Setting: Ebonyi State University Teaching Hospital,

clinical setting.

Population: Medical students who had their stethoscopes.

Purpose: to gather information regarding demography,

handwashing stethoscope usage, and handling and

maintenance practices.

Method: anonymous questionnaire.

Results: of 201 stethoscopes, 161 (80.1%) had bacterial

contamination.(Uneke, Ogbonna, Oyibo & Ekuma, 2009).

Study 2: Bacterial Contamination of Stethoscopes on the

Intensive Care Unit

Setting: 12 beds mixed surgical and medical ICU.

Population: 44 healthcare workers.

Purpose: to determine the rate of cleaning stethoscopes and

types of disinfectants/bacteria

Methods: questionnaires regarding frequency of stethoscope

cleaning with sterile cotton balls and inoculated into

MacConkey agar plates.

Results: Pathogenic bacteria present on stethoscopes.

Alcohol wipes preferred.

Schroeder, Schroeder& D’Amico, 2009

(Whittington, Whitlow, Hewson, Thomas & Brett, 2009)

References:

Merlin, M.A., Wong, M.L., Pryor, P.W., Rynn, K., Marques-Baptista, A., Perritt, R., Stanescu, C.G. & Fallon, T. (2008).

Prevalence of methicillin-restant staphylococcus aureus on the stethoscopes of emergency medical services providers.

Prehospital Emergency Care, 13(1), 71-74. doi 10.1080/10903120802471972

Schroeder, A., Schroceder, M.A. & D’Amico, F. (2009). What’s growing on your stethoscope? The Journal of Family

Practice, 58 (8), 404-408. Retrieved from EBSCOhost.

Uneke, C.J., Ogbonna, A., Oyibo, P.G. & Ekuma, U. (2009). Bacteriological assessment of stethoscopes used by

medical students in Nigeria: Implications for nosocomial infection control. Healthcare Quarterly, 12(3), 132-138.

Retrieved from http://www.longwoods.com/content/20887.

Uneke, C.J., Ogbonna, A., Oyibo, P.G. & Onu, C.M. (2010). Bacterial contamination of stethoscopes used by health workers: Public health implications. J Infect Dev Ctries, 4(7), 436-441. Retrieved from http://www.jidc.org/index.php/journal/article/view/20818091/414.

Whittington, A.M., Whitlow, G., Hewson, D., Thomas, C., & Brett, S.J. (2009). Bacterial contamination of stethoscopes on the intensive care unit. Journal of the Association of Anaesthetists of Great Britain and Ireland, 64, 620-624. doi: 10.1111/j.1365-2044.2009.05892.x

FACULTY TRAINING STRATEGIES

Raised awareness of the need for incorporation of the QSEN Competencies – ie showed Lewis Blackman & Chasing Zero videos

Buy in from faculty regarding Student Learning Outcomes representing QSEN/IOM competencies.

Lewis Blackman video has been incorporated into the curriculum for student viewing

Faculty discussions about existing exercises that could be incorporated into current classes

Adopted the philosophy of a culture of safety and root cause analysis for student error

SO NOW WHAT?

New Student Learning Outcomes based on IOM Competencies

Semester meetings during summer to plan assignments

One Day workshop for part time faculty

Dedicated planning time at each faculty meeting