The Clinical Nurse Specialist as Change Agent in Bridging the Gap Between Inpatient and Outpatient Management of Pulmonary Hypertension Patients

2.50
Hdl Handle:
http://hdl.handle.net/10755/164060
Category:
Abstract
Type:
Presentation
Title:
The Clinical Nurse Specialist as Change Agent in Bridging the Gap Between Inpatient and Outpatient Management of Pulmonary Hypertension Patients
Author(s):
Warfield, Karen
Author Details:
Karen Warfield, RN, MS, APRN-BC, Mayo Clinic, Rochester, Minnesota, USA, email: nacnsorg@nacns.org
Abstract:
Problem: Areas needing improvement within the inpatient and outpatient management, and nursing care of patients with pulmonary hypertension on IV Epoprostenol (Flolan) were identified. Nurses in the inpatient setting were not fully prepared to care for pulmonary hypertension patients on Epoprostenol (Flolan) continuous infusions. The infrequency of these patients makes it difficult for nursing staff to stay competent on the intricacies of the practice issues. Other problems identified were inconsistency in practice between inpatient and outpatient areas. Purpose: To formulate a system in which pulmonary hypertension patients on IV Epropostenol (Flolan) were better managed through the continuum of care. To develop the skill hospital nurses need to be competent and resourceful when caring for a pulmonary hypertension patient on an Epropostenol (Flolan) continuous infusion. To use evidence based research to drive a change in practice in both the inpatient and outpatient areas. Background/Rationale: To meet the unique demands of evaluation and management of patients with primary and secondary pulmonary hypertension, and to facilitate delivery of complex chronic therapeutic regimens, Mayo Clinic initiated the Pulmonary Hypertension Clinic in January 1996. When patients with documented or proven pulmonary hypertension are seen in this clinic, a concentrated multidisciplinary approach is undertaken with involvement by experienced cardiologists, pulmonologists, general and transplant surgeons, clinical investigators (research specialists), and dedicated nursing staff. With the increase in number of outpatients seen with this diagnosis, and the increased longevity of these patients, the inpatient practice at this tertiary care center has experienced more patients with home-managed Epoprostenol (Flolan) infusions. Individuals on IV Epoprostenol (Flolan) infusions are taught that there are few medical institutions in the nation that administer or are knowledgeable about this medication. They are taught to be responsible for mixing and administering the medication and for knowing the implications of administering the infusion. When these patients who self-manage the Flolan infusion are admitted to a hospital for a secondary reason other than pulmonary hypertension management of Flolan becomes a problem. This is because this medication is infrequently used and working with it is complex. In Rochester, patients with this complex medication are often treated as outpatients but may be admitted to any specialty floor in one of two hospitals on an infrequent basis. With the enhanced survival rate of these pulmonary hypertension patients they are occasionally being hospitalized with their home infusion for reasons other than their pulmonary hypertension. An opportunity to improve consistency between inpatient and outpatient nursing management of these patients became evident. Even though more patients with the self administered IV Epoprostenol (Flolan) infusion are being hospitalized, the number of patients seen in the inpatient setting is low (approximately 30 per year). The infrequency of these patients makes it difficult for nursing staff to stay competent on the intricacies of the practice issues. Some of the obstacles identified were: safety issues regarding the administration of the medication in the hospital, a lack of nursing knowledge regarding the specialty needs of someone on IV Epoprostenol (Flolan), a lack of a systematic approach for starting a patient on IV Epoprostenol (Flolan) and getting them involved in the outpatient program, and an inconsistent approach to nursing cares of this patient population across the care continuum. Practice Innovation/Methods: While there is literature on the effectiveness of IV Epoprostenol (Flolan) in class III and class IV pulmonary hypertension there is little literature on the intricacies of its administration. Having worked with this inpatient population quite extensively it was fitting for the Medical Cardiac Critical Care Clinical Nurse Specialist (ICU CNS) and the Medical Cardiology Interventional Clinical Nurse Specialist to become involved in consolidating the inpatient and outpatient pulmonary hypertension practice regarding IV Epoprostenol« (Flolan) administration. The ICU CNS facilitated a multi-disciplinary team and was instrumental in the writing and implementation of institutional guidelines, ambulatory practice guidelines, an outpatient/inpatient referral system and the development of the "Pulmonary Hypertension Infusion" order set. The multidisciplinary team that formed was charged with looking at the inpatient management of the pulmonary hypertension patient. The team consisted of two pharmacists, an ambulatory pulmonary hypertension nurse, the medical chair of the pulmonary hypertension service, a pulmonologist, a discharge planner, the two cardiac clinical nurse specialists identified earlier, and a member of the Institutional Medication Use Process Committee. After several months of meeting an institutional guideline directing the care of a patient on IV Epoprostenol (Flolan) was drafted and approved. In close collaboration with the ambulatory pulmonary hypertension nurses and physicians, the ICU CNS updated the ambulatory practice guidelines to include the current intravenous nursing standards of practice. Also implemented was a referral system in which the outpatient nurses would be notified when one of their patients was admitted to either hospital within the Rochester Mayo Health System. It was a collaborative team effort to put into practice a "Pulmonary Hypertension Infusion" order set with the assistance of the other cardiac clinical nurse specialist, a unit pharmacist and two medical staff. This order set incorporated JCAHO standards of practice. In working closely with the pharmacy division, use of the order set will be mandated with any administration of IV Epoprostenol (Flolan) or subcutaneous Treprostinil (Remodulin) within the two Rochester based hospitals. An educational plan is currently underway to inform all specialty areas of the institutional guideline, available resources, the "Pulmonary Hypertension Infusion" order set and the administration intricacies associated with IV Epoprostenol (Flolan). Evaluation: The Institutional Guideline for care of the inpatient pulmonary hypertension patient on IV Epoprostenol (Flolan) is in the last phase of the approval process before implementation across the institution can occur. The order set on IV Epoprostenol (Flolan) and subcutaneous Treprostinil (Remodulin) is finished and in use. The nursing practice regarding the care of this patient population has already changed in the medical cardiovascular specialty area, as well as in the outpatient Pulmonary Hypertension Clinic; however, education to the other seven intensive care units and designated intermediate care areas has just begun. Outcomes have been identified and the plan is to collect data on an annual basis. Implications for Practice: The intent of the practice change was to improve upon and strengthen the institutional approach to caring for the pulmonary hypertension patient across the care continuum. By using evidence-based standards of practice and a multidisciplinary approach the ICU CNS was able to identify, and impact, practice in the acute medical cardiac intensive care unit. Standardization of inpatient and outpatient practice was accomplished along with providing nursing with resources regarding the care of a patient with pulmonary hypertension. It is predicted that patient costs, time and stress will be influenced with the new practice. We anticipate this practice change will bridge the gap across the continuum of inpatient and outpatient care.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2004
Conference Name:
2004 NACNS Conference, Renaissance in CNS Practice: Transforming Nursing in the 21st Century
Conference Host:
NACNS - National Association of Clinical Nurse Specialists
Conference Location:
San Antonio, Texas, USA
Description:
Conference theme: Renaissance in CNS Practice: Transforming Nursing in the 21st Century, held on March 11 to 13, 2004 in San Antonio, Texas, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleThe Clinical Nurse Specialist as Change Agent in Bridging the Gap Between Inpatient and Outpatient Management of Pulmonary Hypertension Patientsen_GB
dc.contributor.authorWarfield, Karenen_US
dc.author.detailsKaren Warfield, RN, MS, APRN-BC, Mayo Clinic, Rochester, Minnesota, USA, email: nacnsorg@nacns.orgen_US
dc.identifier.urihttp://hdl.handle.net/10755/164060-
dc.description.abstractProblem: Areas needing improvement within the inpatient and outpatient management, and nursing care of patients with pulmonary hypertension on IV Epoprostenol (Flolan) were identified. Nurses in the inpatient setting were not fully prepared to care for pulmonary hypertension patients on Epoprostenol (Flolan) continuous infusions. The infrequency of these patients makes it difficult for nursing staff to stay competent on the intricacies of the practice issues. Other problems identified were inconsistency in practice between inpatient and outpatient areas. Purpose: To formulate a system in which pulmonary hypertension patients on IV Epropostenol (Flolan) were better managed through the continuum of care. To develop the skill hospital nurses need to be competent and resourceful when caring for a pulmonary hypertension patient on an Epropostenol (Flolan) continuous infusion. To use evidence based research to drive a change in practice in both the inpatient and outpatient areas. Background/Rationale: To meet the unique demands of evaluation and management of patients with primary and secondary pulmonary hypertension, and to facilitate delivery of complex chronic therapeutic regimens, Mayo Clinic initiated the Pulmonary Hypertension Clinic in January 1996. When patients with documented or proven pulmonary hypertension are seen in this clinic, a concentrated multidisciplinary approach is undertaken with involvement by experienced cardiologists, pulmonologists, general and transplant surgeons, clinical investigators (research specialists), and dedicated nursing staff. With the increase in number of outpatients seen with this diagnosis, and the increased longevity of these patients, the inpatient practice at this tertiary care center has experienced more patients with home-managed Epoprostenol (Flolan) infusions. Individuals on IV Epoprostenol (Flolan) infusions are taught that there are few medical institutions in the nation that administer or are knowledgeable about this medication. They are taught to be responsible for mixing and administering the medication and for knowing the implications of administering the infusion. When these patients who self-manage the Flolan infusion are admitted to a hospital for a secondary reason other than pulmonary hypertension management of Flolan becomes a problem. This is because this medication is infrequently used and working with it is complex. In Rochester, patients with this complex medication are often treated as outpatients but may be admitted to any specialty floor in one of two hospitals on an infrequent basis. With the enhanced survival rate of these pulmonary hypertension patients they are occasionally being hospitalized with their home infusion for reasons other than their pulmonary hypertension. An opportunity to improve consistency between inpatient and outpatient nursing management of these patients became evident. Even though more patients with the self administered IV Epoprostenol (Flolan) infusion are being hospitalized, the number of patients seen in the inpatient setting is low (approximately 30 per year). The infrequency of these patients makes it difficult for nursing staff to stay competent on the intricacies of the practice issues. Some of the obstacles identified were: safety issues regarding the administration of the medication in the hospital, a lack of nursing knowledge regarding the specialty needs of someone on IV Epoprostenol (Flolan), a lack of a systematic approach for starting a patient on IV Epoprostenol (Flolan) and getting them involved in the outpatient program, and an inconsistent approach to nursing cares of this patient population across the care continuum. Practice Innovation/Methods: While there is literature on the effectiveness of IV Epoprostenol (Flolan) in class III and class IV pulmonary hypertension there is little literature on the intricacies of its administration. Having worked with this inpatient population quite extensively it was fitting for the Medical Cardiac Critical Care Clinical Nurse Specialist (ICU CNS) and the Medical Cardiology Interventional Clinical Nurse Specialist to become involved in consolidating the inpatient and outpatient pulmonary hypertension practice regarding IV Epoprostenol« (Flolan) administration. The ICU CNS facilitated a multi-disciplinary team and was instrumental in the writing and implementation of institutional guidelines, ambulatory practice guidelines, an outpatient/inpatient referral system and the development of the "Pulmonary Hypertension Infusion" order set. The multidisciplinary team that formed was charged with looking at the inpatient management of the pulmonary hypertension patient. The team consisted of two pharmacists, an ambulatory pulmonary hypertension nurse, the medical chair of the pulmonary hypertension service, a pulmonologist, a discharge planner, the two cardiac clinical nurse specialists identified earlier, and a member of the Institutional Medication Use Process Committee. After several months of meeting an institutional guideline directing the care of a patient on IV Epoprostenol (Flolan) was drafted and approved. In close collaboration with the ambulatory pulmonary hypertension nurses and physicians, the ICU CNS updated the ambulatory practice guidelines to include the current intravenous nursing standards of practice. Also implemented was a referral system in which the outpatient nurses would be notified when one of their patients was admitted to either hospital within the Rochester Mayo Health System. It was a collaborative team effort to put into practice a "Pulmonary Hypertension Infusion" order set with the assistance of the other cardiac clinical nurse specialist, a unit pharmacist and two medical staff. This order set incorporated JCAHO standards of practice. In working closely with the pharmacy division, use of the order set will be mandated with any administration of IV Epoprostenol (Flolan) or subcutaneous Treprostinil (Remodulin) within the two Rochester based hospitals. An educational plan is currently underway to inform all specialty areas of the institutional guideline, available resources, the "Pulmonary Hypertension Infusion" order set and the administration intricacies associated with IV Epoprostenol (Flolan). Evaluation: The Institutional Guideline for care of the inpatient pulmonary hypertension patient on IV Epoprostenol (Flolan) is in the last phase of the approval process before implementation across the institution can occur. The order set on IV Epoprostenol (Flolan) and subcutaneous Treprostinil (Remodulin) is finished and in use. The nursing practice regarding the care of this patient population has already changed in the medical cardiovascular specialty area, as well as in the outpatient Pulmonary Hypertension Clinic; however, education to the other seven intensive care units and designated intermediate care areas has just begun. Outcomes have been identified and the plan is to collect data on an annual basis. Implications for Practice: The intent of the practice change was to improve upon and strengthen the institutional approach to caring for the pulmonary hypertension patient across the care continuum. By using evidence-based standards of practice and a multidisciplinary approach the ICU CNS was able to identify, and impact, practice in the acute medical cardiac intensive care unit. Standardization of inpatient and outpatient practice was accomplished along with providing nursing with resources regarding the care of a patient with pulmonary hypertension. It is predicted that patient costs, time and stress will be influenced with the new practice. We anticipate this practice change will bridge the gap across the continuum of inpatient and outpatient care.en_GB
dc.date.available2011-10-27T11:41:15Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:41:15Z-
dc.conference.date2004en_US
dc.conference.name2004 NACNS Conference, Renaissance in CNS Practice: Transforming Nursing in the 21st Centuryen_US
dc.conference.hostNACNS - National Association of Clinical Nurse Specialistsen_US
dc.conference.locationSan Antonio, Texas, USAen_US
dc.descriptionConference theme: Renaissance in CNS Practice: Transforming Nursing in the 21st Century, held on March 11 to 13, 2004 in San Antonio, Texas, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_US
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