Margaret J. Carman

Use of a Clinical Decision Support Tool to improve guideline adherence for the treatment of methicillin-resistant Staphylococcus aureus: Skin and Soft Tissue Infections.

Skin and Soft Tissue Infections (SSTIs) with abscess are commonly seen in the Emergency Department (ED) setting. Given the increasing prevalence of methicillin-resistant Staphylococcus-aureus (MRSA)–related abscesses, appropriate evidence-based decisions are essential in assuring successful treatment. Provider adherence to clinical guidelines for the treatment of SSTIs with presumed MRSA remains inconsistent in terms of prescriptive practice related to antibiotic selection, culturing wounds, and patient discharge recommendations regarding the use of infection control techniques. Evidence indicates that the use of Clinical Decision Support (CDS) tools is valuable in improving provider awareness and adherence to clinical guidelines. This study was conducted to examine whether the development of a CDS tool to guide order entry for the treatment of MRSA-related SSTIs and embed it into the electronic medical record program would improve provider adherence to the North Carolina Consensus Guideline for Management of Suspected Commmunity-Acquired MRSA Skin and Soft Tissue.

Improving comfort and throughput for patients undergoing fractionated laser ablation of symptomatic burn scars.

IntroductionUtilization of fractionated ablation with a carbon dioxide (CO2) laser has shown to be efficacious in the management of symptomatic burn scars. Although effective, this procedure is painful and burn patients traditionally evidence low pain tolerance. For this reason intravenous anesthesia is used during these procedures. However, operative anesthetics and intravenous opioids are associated with patient discomfort postoperatively and prolonged recovery times. The American Society of Anesthesiologists’ (ASA) Task Force on Acute Pain Management for the perioperative setting recommends the use of multimodal anesthesia, including the use of regional blockade with a local anesthetic. A quality improvement project was implemented to incorporate this practice and evaluate outcomes. The main goal of this project was to improve patient comfort as evidenced by improved pain scores with a decreased requirement for intravenous opioids post-procedure. The secondary goal of this project was to improve patient throughput in the setting of an outpatient surgical facility as evidenced by decreased time in the facility. MethodsA historic cohort of 36 cases was compared to 36 cases managed under the ASA guidelines for multimodal anesthesia utilizing a topical local anesthetic. Statistical analysis included a t-test for continuous variables while chi square was utilized to analysis dichotomous variables. ResultsIntravenous narcotic utilization and mean pain scores in the recovery phase of care were significantly reduced as a result of adoption of the ASA recommendations. Throughput time increased by 36 minutes; notably in the preoperative phase, while patient movement through the procedural phase was significantly decreased as was procedure to discharge times. ConclusionsImplementing the use of a topical anesthetic as a component of multimodal anesthesia for patients undergoing fractionated laser ablation of symptomatic burn scars can significantly decrease patient pain and the need for intravenous opioids during the recovery phase of care. Increased overall throughput times were noted primarily in the preoperative period, while procedure to discharge times decreased. As operative and recovery phases represent higher operational costs, decreased time in these areas represent potential cost savings for the facility.

Bundling the death and dying learning experience for prelicensure nursing students.

One of the greatest challenges in nursing education lies in linking classroom content to the clinical environment. Simulation is now an established method for allowing students to practice the skills and techniques discussed in didactic nursing education and to allow this to occur in a safe, controlled environment before moving into the real world of clinical practice. Multidimensional learning bundles, such as the End-of-Life Nursing Education Consortium curriculum, provide an opportunity to link theoretical content with practice, yet time constraints may limit implementation of the full curriculum. A compacted learning bundle with a didactic component, unfolding case study, and video-recorded family conference to prepare students for a simulation on care of the dying patient is being used in 1 accelerated bachelor of science in nursing program to address students’ learning needs.

Evaluation of the effect of the modified early warning system on the nurse-led activation of the rapid response system.

The Modified Early Warning System (MEWS) is a scoring rubric used to detect the earliest signs of a change in a patients condition. This mixed-methods study used pre- and postintervention data to describe the impact of the MEWS on the frequency of rapid response system activations and cardiopulmonary arrests among patients admitted to medical-surgical units. Focus groups of nursing staff provided insight into the factors that influence how nurses use the MEWS at the bedside as a framework to identify, intervene, and manage patients in need of an advanced level of care.

Standards of Practice for Emergency Nurse Practitioners.

ENPs are specialized licensed practitioners, who possess the necessary clinical competencies to provide optimal care to patients in ambulatory, urgent, and emergent care settings. ENP specialization builds upon NP entryinto-practice knowledge and skills and requires a minimum of a master’s level preparation or specialized preparation at the post-master’s or doctoral level. ENPs demonstrate competencies by applying standardized care guidelines in their clinical practice. Other ways of continuing competencies include participation in maintaining continuing education, quality improvement processes and peer reviewsincluding the systematic periodic review of records and treatment planswhile maintaining specialty and population-focused certification in compliance with current laws and regulations.

The Experience of Advanced Practice Nurses in US Emergency Care Settings

Introduction Little information has been published regarding the actual practice, training, and validation of basic skills and competencies needed by the advanced practice registered nurse (APRN) in the emergency care setting. The purpose of this study was to (1) identify skills being performed by APRNs practicing in emergency care settings (2); explore types of training; and (3) describe competency validation. Additionally, we explored frequency of skill use and facilitators and barriers to performing a skill to the full extent of training and education. Methods An exploratory mixed‐methods study was performed incorporating a self‐report survey and focus group interviews. Results The educational path to advanced practice nursing in emergency care settings is not standardized. Few programs incorporate or address the need for APRNs to receive acute care training across the life span, which is the hallmark of emergency nursing practice. Similarly, training is reported as fragmented, and validation of skills for both nurse practitioners and clinical nurse specialists can vary. APRN practice autonomy is affected by the presence of other providers (specifically physicians), institutional culture, and state boards of nursing that regulate practice. Discussion Integrated educational and orientation programs are needed that address high‐acuity patients across the life span. Additionally, a more nuanced approach to assessing APRN capabilities as a combination of hard (clinical emergency) and soft (communication and organizational) skills may be an appropriate framework within which to examine the advanced practice role. Future research should continue to evaluate training, competency assessment, and outcomes for APRNs in the emergency care setting.

Searching the literature: what is known (and not known) about your topic?

n the previous articles in this series (appearing in the November 2012, March 2013, and May 2013 1–3 I issues), we have discussed how evidence can change practice, how to evaluate evidence, and how to develop a clinical question. At this point in the process, you need to find out more about your problem to create workable interventions. For example, who is the best health care professional to perform triage? This is a good question; however, what do you know about this problem and possible solutions that are already in use? Before you can begin to plan to address a clinical problem, you must know what is known and not known about your particular problem. A literature search will familiarize you with the work that has already been done in your area of interest or inquiry. It should be a comprehensive survey of all publications and other information about a specific topic. The search will produce a list of references on the topic of interest.

Use of a Virtual Learning Platform for Distance-Based Simulation in an Acute Care Nurse Practitioner Curriculum

Background: Acute care nurse practitioner (ACNP) programs that use high-fidelity simulation as a teaching tool need to consider innovative strategies to provide distance-based students with learning experiences that are comparable to those in a simulation laboratory. Objective: The purpose of this article is to describe the use of virtual simulations in a distance-based ACNP program and student performance in the simulations. Method: Virtual simulations using iSimulate were integrated into the ACNP course to promote the translation of content into a clinical context and enable students to develop their knowledge and decision-making skills. With these simulations, students worked as a team, even though they were at different sites from each other and from the faculty, to manage care of an acutely ill patient. Results: The students were assigned to simulation groups of 4 students each. One week before the simulation, they reviewed past medical records. The virtual simulation sessions were recorded and then evaluated. The evaluation tools assessed 8 areas of performance and included key behaviors in each of these areas to be performed by students in the simulation. More than 80% of the student groups performed the key behaviors. Discussion: Virtual simulations provide a learning platform that allows live interaction between students and faculty, at a distance, and application of content to clinical situations. With simulation, learners have an opportunity to practice assessment and decision-making in emergency and high-risk situations. Simulations not only are valuable for student learning but also provide a nonthreatening environment for staff to practice, receive feedback on their skills, and improve their confidence.

Henoch-Schönlein Purpura in the ED.

Diagnosing and treating a child with the most common form of pediatric vasculitis.

Benefits to ED Nurses Participating in Interdisciplinary Research

Authors: Kathleen E. Zavotsky, MS, RN, CEN, ACNS-BC, CCRN, Lisa A. Wolf, PhD, RN, CEN, FAEN, Kathy M. Baker, PhD, RN, NE-BC, Margaret J. Carman, DNP, ACNP-BC, CEN, Paul R. Clark, PhD, MA, RN, Kevin Langkeit, MSN, RN, Gail Lenehan, EdD, MSN, FAEN, FAAN, and Michael Moon, PhD, MSN, RN, CEN, CNS-CC, FAEN, New Brunswick, NJ, Des Plaines, IL, Richmond, VA, Durham, NC, Louisville, KY, Bountiful, UT, Boston, MA, and San Antonio, TX Section Editors: Lisa A. Wolf, PhD, RN, CEN, FAEN