Nursing Institute - Cleveland ClinicIn 2007, the Nursing Institute continued to place emphasis on evidence-based nursing practices by conducting, translating and disseminating nursing

Outcomes | 2007

Nursing Institute

Patients First

Nursing Institute1

Outcomes 2007

Quality counts when referring patients to hospitals and physicians, so Cleveland Clinic has created a series of Outcomes

books similar to this one for many of its institutes. Designed for a healthcare provider audience, the Outcomes books

contain a summary of our nursing trends and approaches, data on patient volume and outcomes, and a review of new

technologies and innovations.

Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes

for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase outcomes

reporting each year. When outcomes for a specific treatment are unavailable, we often report process measures that

have documented relationships with improved outcomes. When process measures are unavailable, we report volume

measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical

technique.

Cleveland Clinic also supports transparent public reporting of healthcare quality data and participates in the following

public reporting initiatives:

• Joint Commission Performance Measurement Initiative (www.qualitycheck.org)

• Centers for Medicare and Medicaid (CMS) Hospital Compare (www.hospitalcompare.hhs.gov)

• Leapfrog Group (www.leapfroggroup.org)

• Ohio Department of Health Service Reporting (www.odh.state.oh.us)

Our commitment to providing accurate, timely information about patient care is designed to help patients and referring

physicians make informed healthcare decisions. We hope you find these data valuable. To view all our Outcomes books,

visit Cleveland Clinic’s Quality and Patient Safety website at clevelandclinic.org/quality/outcomes.

22

Dear Colleague:

I am proud to present the 2007 Cleveland Clinic Outcomes books. These books provide information on results, volumes and innovations

related to Cleveland Clinic care. The books are designed to help you and your patients make informed decisions about treatments and

referrals.

Over the past year, we enhanced our ability to measure outcomes by reorganizing our clinical services into patient-centered institutes. Each

institute combines all the specialties and support services associated with a specific disease or organ system under a single leadership at a

single site. Institutes promote collaboration, encourage innovation and improve patient experience. They make it easier to benchmark and

collect outcomes, as well as implement data-driven changes.

Measuring and reporting outcomes reinforces our commitment to enhancing care and achieving excellence for our patients and referring

physicians. With the institutes model in place, we anticipate greater transparency and more comprehensive outcomes reporting.

Thank you for your interest in Cleveland Clinic’s Outcomes books. I hope you will continue to find them useful.

Sincerely,

Delos M. Cosgrove, MD

CEO and President

what’s insideChairman’s Letter 04

Institute Overview 05

Quality and Outcomes Measures

Quality Indicators 09

Advanced Practice Nursing 12

Ambulatory Nursing 13

Behaviorial Health 15

Cancer Center 16

Pediatric Institute & Children’s Hospital 18

Critical Care/Medical Intensive Care Unit 22

Critical Care/Surgical Intensive Care Unit 23

Emergency Services 24

Heart & Vascular Institute 26

Medicine 30

Surgical Floors 32

Surgical Services/Operation Room 34 and Post Anesthesia Care Unit

Patient Experience 36

Innovations 39

New Knowledge 44

Leadership Team 47

Contact Information 48

Institute Locations 48

Cleveland Clinic Overview 49

Online Services 49 eCleveland Clinic DrConnect MyConsult

Outcomes 2007 44

Chairman’s LetterI am pleased to present our fourth edition of Outcomes. This brief overview

focuses on initiatives from the Nursing Institute at the Cleveland Clinic where

we are challenged to meet the clinical, administrative and research demands

of nursing today. It demonstrates Cleveland Clinic nurses are members of the

interdisciplinary care team and serve as an integral part of the overall patient

care experience with an emphasis on patient safety and quality care.

The information in this booklet will show the Nursing Institute at the

Cleveland Clinic has much to be proud of in 2007. We recognize the need to

foster innovation, continually educate and develop our nurses and anticipate

the changing healthcare environment. It is the front line caregivers who

make decisions regarding nursing care interventions and changes to practice

in their unit practice councils. Those decisions spread Institute-wide through

shared governance councils with nursing research and the resulting evidence

continually guiding our practice decisions. Also demonstrated are innovative

administrative practices that support the clinical arena.

Transparency is the ability to illuminate the quality of our healthcare and has

become an expectation of many healthcare consumers. Therefore, it is our

hope that by sharing this information with our colleagues, we can impact the

quality of patient care not only at Cleveland Clinic but outside our own walls.

It is our wish to use this communication tool to share our best practices as

we continue to advance the science of nursing. Because at the Cleveland

Clinic, we believe we are the destination for nursing practice.

Claire M. Young, RN, MSN, MBAChief Nursing Officer and Chair, Nursing Institute

5 Nursing Institute5

Institute OverviewThe Nursing Institute at Cleveland Clinic is composed of registered nurses;

licensed practical nurses; nurse associates; patient care nursing assistants;

clinical, surgical and equipment technicians; patient service associates;

clinical instructors; clinical nurse specialists; advanced practice nurses;

paramedics and health unit coordinators who provide best in class care to

our patient populations. Nurses and support staff practice on more than

40 specialty-based nursing units, including 14 intensive care units, an

emergency department and clinical decision unit, a hospital transfer unit,

a 59-bed subacute care unit and 59 operating rooms. More than 300

advanced practice nurses including certified nurse practitioners, certified

registered nurse anesthetists, clinical nurse specialists and certified nurse

midwives collaborate with physicians to manage patient care in the

inpatient, outpatient and perioperative settings.

The Nursing Institute sponsors multiple educational programs on the

main campus, including a patient care nursing assistant training program,

a surgical technician training program in collaboration with Cuyahoga

Community College and programs to prepare nurse anesthetists and

enterostomal therapy and wound care nurses for the specialized roles they

fulfill in patient care.

The inaugural class of the partnership with Cuyahoga Community College

under the auspices of a U.S. Division of Labor grant completed their

program of study in December and are eligible to take the licensure exam.

In September, the second class of current employees seeking to become

registered nurses began their studies. This class will complete the program

in December 2008.

In December 2007, the Division of Nursing officially became the Nursing

Institute of Cleveland Clinic.

Awards and Accolades

The hospitals, outpatient clinics, home care programs, ambulatory

surgery centers and family health centers of Cleveland Clinic maintained

accreditation by the Joint Commission.

In 2003, Nursing Institute staff achieved Magnet Status, the recognition of

excellence in nursing by the American Nurses Credentialing Center (ANCC).

Documents for Magnet redesignation were submitted and accepted in

2007 with a subsequent survey expected in early 2008. Cleveland Clinic

was the 3rd hospital in Ohio to achieve this recognition and the 72nd in

the United States.

According to the 2007 U.S. News & World Report “America’s Best

Hospitals” survey, Cleveland Clinic is one of the top four hospitals in the

United States. Cleveland Clinic’s Heart Center has been ranked first in

the nation for the past 13 years and 16 of its specialties rank among the

nation’s top 10.

Cleveland Clinic and its community hospitals were again recognized as

2007 NorthCoast 99 award winners, indicating great workplaces for top

performers in the Northeast Ohio area.

Nursing Education and Research

Nursing practice has changed dramatically over the past few decades.

Technological advances in healthcare, coupled with increasing patient

acuity and complexity of care at Cleveland Clinic, challenge the nurse

to integrate skills, decision making and critical thinking at a pace not

previously encountered in the clinical setting. The standard and uniform

teaching plans and methods of the past have been enthusiastically

replaced with innovative, engaging and active teaching-learning strategies

and environments.

The newly established Learning Center for Nursing Practice Excellence is a

wireless facility that includes computer labs, distance learning classrooms

and a state-of-the-art skills lab. Whether online or in-person, simulated

clinical experiences provide nurses and nursing students of all levels the

milieu in which to develop problem-solving and decision-making abilities

in a safe, simulated environment. The ultra-modern skills lab is designed

to replicate the practice settings of the medical-surgical, intensive care,

operating room, pediatric and maternity units and features advanced

human patient simulators, mobile bedside computers with access to on-

line clinical documentation and the Internet as well as digitalized video and

event debriefing printouts.

Technology alone will not enhance learning outcomes, but the promotion

of realism in the practice environment featuring full-mission scenarios,

interactive case studies and modeling by educators will significantly affect

practice competencies while increasing the confidence and comfort level

of nurses. With the new teaching/learning opportunities afforded by all

6Outcomes 2007

2003 2004 2005 2006 2007

54,00054,000

ICU Patient DaysICU Patient Days

44,00044,000

49,00049,000

34,00034,000

39,00039,000

2003 2004 2005 2006 2007

270,000270,000

Non-ICU Patient DaysNon-ICU Patient Days

240,000240,000

255,000255,000

210,000210,000

225,000225,000

aspects of the Learning Center, a new experiential orientation program has

evolved to include a phased process that allows the student to progress

from simple to complex concepts and skills. Allowing for more clinical

time, this process provides immediate opportunity for the application of

information and skills learned in the classroom setting.

As our education focus moves beyond content to critical thinking and

clinical judgment skills, we have the ability to provide exceptional

opportunities for nurses, from novice to expert, to develop and enhance

the professional practice of nursing.

Online Clinical Placement Tool

Clinical rotation sites for affiliating schools of nursing remain in high

demand. In an effort to assist the schools and increase capacity, the

Cleveland Clinic participated in a major pilot project to evaluate the use of

an online clinical placement tool. Working in collaboration with the North-

east Ohio Nursing Initiative, personnel from Cleveland Clinic served on the

Pilot Committee with 13 schools/colleges of nursing that tested the tool.

Cleveland Clinic has now expanded use of the on-line clinical placement

tool to include all of the Cleveland Clinic hospitals. The transparency

and effectiveness of the tool has opened up new clinical opportunities

and afforded faster turnaround for clinical placement between schools of

nursing and clinical agencies.

Nursing Research

In 2007, the Nursing Institute continued to place emphasis on evidence-

based nursing practices by conducting, translating and disseminating

nursing research. Twelve new nurse-initiated research studies received

Institutional Review Board approval, 36 nursing research projects were in

progress and 27 projects were completed by the end of the year. Findings

from research help shape nursing care practices that lead to improved

patient outcomes and nurse efficiencies, and provide knowledge used in

nursing management decisions.

Patient Volumes

The increase in intensive care unit (ICU) patient days reflects the addition

of eight neurosurgical ICU beds, as well as the increasing complexity of

patients cared for at Cleveland Clinic.

The increase in non-ICU patient days has resulted in several efforts

aimed at improving patient throughput. One of these efforts has been the

initiation of daily rounds with Nursing and Case Management to identify

patients who may be ready for discharge in the next 24 hours. Additionally,

the increased use of Nurse Practitioners and Physician Assistants helps

enhance communication among all care provider team members.

Nursing Institute7

2003 2004 2005 2006 2007

1,0501,050

Number of Staffed BedsNumber of Staffed Beds

1,0301,030

1,0401,040

1,0101,010

1,0001,000

1,0201,020

New HiresNew Hires600

500

400

300

200

100

02004 2005 2006 2007

RNLPN

% Breakdown of New Hires% Breakdown of New Hires80

60

40

20

02003 2004 2005 2006 2007

Experienced NurseNew Grad

While the number of staffed beds stabilized for 2007, the Nursing Institute

is making plans to support the opening of the new Sydell and Arnold

Miller Family Pavilion, slated to open during the fourth quarter of 2008.

Additionally, a remote Central Monitoring Unit was opened late in the third

quarter of 2007. This unit monitors all telemetry patients throughout the

organization.

The above graph demonstrates significant increases in staff hired. The

new hires support the increased bed capacity and demonstrate the success

of a comprehensive recruitment strategy. For 2007, this strategy included

hiring staff in advance of planned turnover in order to provide consistent

staffing levels.

The percent of new graduate nurses hired continues to increase

significantly. This trend is the result of many efforts aimed at recruiting

senior level nursing students. These initiatives include:

• summer student experience

• nurse associate program

• extended orientation

• nursing education assistance program

• increased on-site clinical rotations for nursing students

The transformation in nursing education has been vital in meeting the

orientation needs of new hires.

A few specific retention efforts included:

• career coaches to assist staff in finding the “right fit” unit

• senior nurse council creating scheduling perks in recognition of tenure

• refresh center to provide night shift staff a place to rest before

driving home

• shared governance driven closed staffing options

• increased staff recognition at quarterly Nursing Town Hall meetings

Outcomes 2007 8

Commitment to Quality and Patient Safety

The Department of Nursing Quality leads the Nursing Institute’s efforts

in the improvement of nursing practice and patient care, as well as the

collection, analysis and utilization of data from nurse quality indicators. In

addition, Nursing Quality coordinates the efforts toward strong unit-level

performance improvement through the Quality Council composed of unit

level staff nurses. This council provides support, education and oversight

to the Institute’s quality initiatives. Unit-based quality representatives

are charged with leading the initiatives for improvement on their units

in conjunction with the unit-based Shared Governance Council and unit

leadership. Additionally, unit-based Patient Safety Officers lead unit specific

teams focusing on identified patient safety concerns. In the past year

the group focused on fall prevention on selected medical nursing units,

environmental concerns and labeling of I.V. tubing and solutions. All of

these efforts have resulted in consistent monitoring and improvement of the

nurse-sensitive indicators over the past year.

Prevention and treatment of hospital-acquired pressure ulcers has been a

focus of activity including a recommitment that “every nurse is a skin care

nurse.” The Skin and Pressure Ulcer Education and Consultation Team

(SPECT), consisting of three certified wound, ostomy and continence nurse

specialists, is the resource for nurses across the continuum regarding

pressure ulcer education and prevention.

Fall prevention continues to be an important focus. Since the

implementation of the Hendrich II Falls Assessment tool in early 2006, a

steady decrease in hospital falls rate has occurred with overall rates near

or below the NDNQI mean. In addition, an Interdisciplinary Fall Prevention

Committee, co-chaired by Nursing Quality and the Nursing Patient Safety

Officer, implemented a process for review of falls-associated medications

by a pharmacist and an improved process for communication between

Physical Therapy and Nursing related to patients at high risk for falls to

reduce the number of falls with injuries significantly.

Patient safety strategic efforts have focused on improving hand hygiene

compliance among healthcare workers and the reduction of clinician

collected specimen errors. Hand hygiene compliance has improved by

instituting an enterprise-wide hand hygiene awareness campaign, improved

accessibility to hand hygiene products and supplying unit-based hand

hygiene compliance rates to each unit on a monthly basis. Unit-Based

Hand Hygiene Champions on each inpatient and ambulatory nursing area

are then charged with leading unit level improvement efforts. Specimen-

labeling teams have targeted selected units to focus improvement efforts

utilizing the Six Sigma methodology. Enhancements to the patient label

and retraining on the proper procedure have been shown to decrease the

number of errors on inpatient nursing units.

Quality patient outcomes are a benchmark for the healthcare environment

today. Patient satisfaction, the Joint Commission’s Core Measures, and

other data elements publicly reported via national databases have further

enhanced attention to quality outcomes. The department collaborates with

the Quality and Patient Safety Institute to coordinate Nursing’s role in the

interdisciplinary efforts related to the improvement of patient outcomes and

the patient experience across the organization.

Nursing Institute9

Quality Indicators

Number of Falls/1000 Patient DaysNumber of Falls/1000 Patient Days

0

0.1

0.2

0.3

0.4

2003* 2004* 2005* 2006* 2007*


0

1

2

3

4

2003* 2004* 2005* 2006* 2007

Falls

Fall and fall injury for hospitalized patients are important indicators of nursing quality.

Fall etiology is related to multiple factors that include patient condition, staffing resources and knowledge and environmental issues.

2007 fall-reduction strategies include:

• Use of an evidence-based fall risk assessment tool

• Prevention strategies based upon the patient’s risk factors

• Consistent handoff communication and team work

• Modifications of environment in patient bathrooms

The national benchmark is based upon the American Nurses Association’s National Database of Nursing Quality Indicators (NDNQI)®. Our hospital is compared to other hospitals (with greater than 500 beds) that participate in NDNQI. Data are stratified per unit type. There are five adult patient unit types: Critical Care Unit, Medical Unit, Surgical Unit, Medical-Surgical Unit and Step-Down Unit.

*Cleveland Clinic, fall rates below NDNQI mean for this unit type.

1.2millionApproximate number of

dollars Cleveland Clinic

spent on nursing education

assistance in 2007

Adult Intensive Care Units Fall Rate

Adult Stepdown Units Fall Rate

Outcomes 2007 10


0

1

2

6

3

4

5

2003* 2004* 2005 2006 2007


0

1

2

6

3

4

5

2003* 2004 2005 2006 2007*


0

0.5

1.0

3.0

1.5

2.0

2.5

2003* 2004* 2005* 2006* 2007

*Cleveland Clinic, fall rates below NDNQI mean for this unit type.

Adult Medical Care Units Fall Rate

Adult Medical-Surgical Units Fall Rate

Adult Surgical Care Units Fall Rate

11 Nursing Institute

ScoreScore

0

5

10

30

15

20

25

Critical Care Step Down* Medical Surgical* Med-Surg*

1st Quarter2nd Quarter3rd Quarter4th Quarter

0

20

40

60

80

100

Critical Care* Step Down Medical* Surgical Med-Surg

Percent at Risk per Unit TypePercent at Risk per Unit Type

Pressure Ulcers Prevention of pressure ulcers is a nursing quality imperative.

Pressure ulcer reduction interventions in 2007 included:

• Restructuring of skin care education and consultation services

• Implementation of multifaceted pressure ulcer reduction program entitled “Every Nurse is a Skin Care Nurse”

• The objectives of this program are to empower every bedside nurse with education, resources and support to develop, implement and revise a patient-specific pressure ulcer prevention plan.

• Implementation of documentation for prevention and treatment of pressure ulcers in the electronic medical record

As described for falls, the pressure ulcer national benchmark is based upon the American Nurses Association’s National Database of Nursing Quality Indicators (NDNQI)®.

Note: Prevalence is measured by observing the skin status of all patients present in the unit at one point in time. The rate is calculated by the number of patients observed to have a hospital-acquired pressure ulcer/ total number of patients observed.

* Indicates that Cleveland Clinic’s

hospital acquired prevalence rate is

below NDNQI mean.

* Indicates that at Cleveland Clinic,

more patients are at risk for skin

breakdown compared to the NDNQI

mean. At risk is based on scores

from a uniform skin assessment

pressure ulcer risk assessment tool

used by participating hospitals.

Percentage of Patients at Risk for Hospital-Acquired Ulcers per Unit Type

18.29Percentage of Cleveland

Clinic nurses with national

certification who provided

direct patient care in 2007.

This number is 2 percent

higher than the previous year.

2007 Hospital-Acquired Prevalence Score per Quarter

Outcomes 2007 12

Advanced Practice Nursing

300 Approximate number

of advanced practice

nurses employed at

Cleveland Clinic.

Average Length of Stay DaysAverage Length of Stay Days

9.5

10.5

11

10.5

10

Unit A:Collaborative APN/PhysicianManaged Unit

Unit B:Physician-onlyManaged Unit

Unit C:Physician-only Managed Unit

N=1106

N=942N=882

Effect of Certified Nurse Practitioner Utilization on Length of Stay in Postoperative Cardiac Surgery PatientsIn January 2007, Cleveland Clinic began utilizing certified nurse practitioners on a postoperative cardiothoracic surgery floor.

• Certified nurse practitioners work collaboratively with surgeons, medical physicians and nursing staff to manage postoperative cardiac surgery patients.

• Certified nurse practitioners’ daily activities include:

• Physical assessment

• Review of laboratory results

• Review / update of medications

• Incision healing / wound care

• Patient self care capabilities / education

• Oral intake / dietary progression

Length of Hospital Stay for Patients Collaboratively Managed by Physicians and Certified Nurse Practitioners versus Patients Managed by Physicians Only

(Jan. 2007- Oct. 2007)

To evaluate the effectiveness of certified nurse practitioners, we examined the average length of hospital stay of cardiac surgery patients cared for by certified nurse practitioners and physicians (see first bar of graph) collaboratively on one nursing unit versus similar patients recovering from cardiac surgery on two nursing units cared for solely by physicians (middle and right bars on graph).

• Length of hospital stay was lower on the nursing unit where patients were managed collaboratively by advanced practice nurses and physicians.


Percent of Excellent RatingsPercent of Excellent Ratings

64

62

60

58

56

54

52

N=19,181

N=36,645

N=37,034 N=36,664

N=19,429

2006 2007

N=19,216

Nursing Staff as Caregivers

Nursing TeamworkStaff Sensitivity to Patient Needs

6.5

7

7.5

8

8.5

9

Pre-Education Post-Education

Mean HbA1cMean HbA1c

N=90

Patient Perception of Ambulatory ClinicsIn 2007, patient ratings in the excellent category rose for nurses as caregivers, nurses being sensitive to patient needs and nursing teamwork. Our nurses continually strive to provide world class service to patients.

Ambulatory Nursing

Diabetic Education by RN Diabetic Educator in an Internal Medicine Ambulatory ClinicA normal hemoglobin (Hb) A1c level is less than 7% of total hemoglobin. Diabetes complications can be delayed or prevented when HbA1c levels are normal/close to normal. After diabetes education classes, HbA1c levels decreased toward normal.

Outcomes 2007 14

3.2 millionApproximate number

of ambulatory patient

visits in 2007

Percent; Rating of Nurses’ Ability to Offer a Clearand Knowledgeable PresentationPercent; Rating of Nurses’ Ability to Offer a Clearand Knowledgeable Presentation

0

20

40

60

80

100

Excellent Very Good Good

N=248

Bariatric Education

Nursing staff sensitivity to needs is imperative

when conducting patient education.

In rating our nurses’ ability to offer a clear

and knowledgeable presentation, 65% of

respondents receiving education in outpatient

bariatric surgery clinics rated it as excellent.


0

10

20

30

40

50

60

70

0

2

4

6

8

10

12

14

Number of Episodes / 1000 Patient DaysNumber of Episodes / 1000 Patient Days

1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q

Seculsion Rate

# Episodes per PatientRestraint Rate

Number of Episodes / 1000 Patient DaysNumber of Episodes / 1000 Patient Days

0

10

20

30

40

50

2005 2006 2007

AssaultsGoal: Provide an emotionally and physically safe environment. At Cleveland Clinic, less than 5% of patients required seclusion, and there was only one episode of mechanical restraints in 2007.

Our success was facilitated by:

• Unit culture based on a collaborative problem-solving approach

• Heightened focus by the interdisciplinary treatment team on prevention and safe physical crisis intervention

• Annual training on non-violent physical crisis intervention

• Review of every episode of assault or seclusion/restraint by nursing leadership

Behavioral Health

Pediatric Restraint and Seclusion

Quarters, 2007 Assaults, N Assaults with injury, N

1st 13 0

2nd 11 0

3rd 4 0

4th 3 0

Annual Pediatric Seclusion Rate

Outcomes 2007 16

Number of Falls / 1000 Patient DaysNumber of Falls / 1000 Patient Days

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul

2006 2007

Aug Sep Oct Nov Dec0

2

4

6

810

12

14

16

18

8

UCL = 17.05

Dec2005

Mean = 7.13

Patient Fall ReductionFalls rates decreased from 9.49 falls per 1,000 patient days in 2006 to 4.8 falls per 1,000 patient days in 2007.

We found that a high percentage of falls occurred around change of shift. As a result of this finding, the patient care nursing assistant change-of-shift report process was altered to occur in patient rooms and specifically address falls information including:

• Patient level of fall risk

• Verification of falls precautionary measures in use

• Other relevant personal care and safety issues

Cancer Center

Over 60Number of shared

governance councils

actively serving to

provide direct care

nurses a voice in

governing their

nursing practice


Percent Correct by NursesPercent Correct by Nurses

CL=0.7344

UCL=0.9559

0.5

0.6

0.7

0.8

0.9

1.0

1

13 Observations per day

2 3 4 85 6 7Week

Compliance with hand hygiene protocols (defined as washing hands for 15 seconds upon entry into a patient’s room and when leaving) was initially at about 60 percent.

A program of monitoring daily compliance was initiated.

The multidisciplinary team consisted of:

• Nurses

• Physicians

• Respiratory therapists

• Environmental Services

• Lab personnel

• Quality representatives

The team identified gaps and opportunities for improvement. Within 5 weeks, compliance rates were above 85 percent and were sustained over time.

Hand Hygiene Compliance on Hematology/Oncology Nursing Floor

Outcomes 2007 18

Percent; Patients Receiving Influenza VaccinePercent; Patients Receiving Influenza Vaccine

0

40

100

2003 2004 2005 2006 2007

Hematology, N = 357

Oncology, N = 747

80

60

20

Influenza Vaccine for Children Receiving ChemotherapyPer protocol, we provide the influenza vaccine to children who are receiving chemotherapy, have been off chemotherapy less than 6 months or have sickle cell disease.

We implemented a process to capture as many patients as possible by:

• Maintaining a list of all patients needing and receiving vaccine

• Mailing reminder letters to all eligible patients

• Making reminder phone calls prior to their appointment

• Providing follow-up flu shot appointments for patients who were ill at the time of their initial visit

Some children may not receive the vaccine due to medical therapies, having received the vaccine from another care provider or if their parents decline administration.

Pediatric Institute & Children’s Hospital


Mean Bloodstream Infections/1000 Patient DaysMean Bloodstream Infections/1000 Patient Days

0

7

2

1

4

5

3

6

2003 2004 2005 2006 2007

PICU

NICU

The Pediatric Institute & Children’s Hospital has been collecting data on bloodstream infections in our intensive care units for several years.

• Neonatal Intensive Care Unit (NICU) mean infection rate has declined from 8.86 to 1.41/1,000 patient days

• Pediatric Intensive Care Unit (PICU) mean infection rate has declined from 5.74 to 1.2/1,000 patient days.

• Interventions used to decrease bloodstream infections included:

• Increased hand hygiene compliance

• Adherence to evidence-based intravenous insertion techniques

• In 2008, we will be joining the National Association of Children’s Hospitals and Related Institutions (NACHRI) Catheter Associated Blood Stream Infection Collaborative to learn more about processes and techniques that will help us further decrease our rates.

Bloodstream Infections in Pediatric and Neonatal Intensive Care Units

454Number of patients

admitted and

treated in Child and

Adolescent Psychiatry

in 2007

Outcomes 2007 20

Rate Per 100 Ventilator Days, 2007Rate Per 100 Ventilator Days, 2007

0

3.0

1.5

1.0

0.5

2.5

2.0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Rate Per 100 Ventilator Days, 2007Rate Per 100 Ventilator Days, 2007

0

2

1

4

5

3


The Children’s Hospital tracks unplanned extubation rates as well as contributing factors, such as level of sedation, duration of intubation and RN:patient ratios. The Pediatric Intensive Care Unit mean rate for 2007 is 0.65/100 ventilator days. Factors thought to positively affect our outcomes are 24-hour pediatric intensivist staff and 1:1 nurse-patient ratio when indicated.

The Neonatal Intensive Care Unit mean unplanned extubation rate for 2007 is 1.20/100 ventilator days. Interventions to decrease unplanned extubations include trialing new ways to secure endotrachael tubes and having two caregivers participate in repositioning intubated babies.

Unplanned Extubations in the Pediatric Intensive Care Unit

1340Number of trips the

Pediatric Transport

Team made in 2007

to facilitate the

medical needs of

pediatric patients.


Percent; Overall Rating of Inpatient Pediatric CarePercent; Overall Rating of Inpatient Pediatric Care

60

70

80

90

100

2006N = 292

2007N = 593

Cleveland ClinicQDM Database

60

70

80

90

100

Percent of Patients Who Received and Understood Discharge InstructionsPercent of Patients Who Received and Understood Discharge Instructions

2006N = 307

2007N = 543

Cleveland Clinic QDM Database

Patient SatisfactionQuality Data Management (QDM) is a national vendor with whom we contract to conduct our patient satisfaction surveys. The following graphs show how we compare against the scores of all hospitals in the QDM database for selected indicators over the past two years.

Outcomes 2007 22

Ventilator-Acquired Pneumonia in the Medical Intensive Care UnitA continued downward trend in the number of cases of ventilator-acquired pneumonia was found in the Medical Intensive Care Unit. Rates based on 1,000 ventilator days showed a drop in rates over time:

• 3.23/1,000 ventilator days in 2005



To progress to zero incidence of ventilator-acquired pneumonia (VAP) in the Medical Intensive Care Unit, use of chlorhexadine swabs for oral care has been added to the protocol that already includes a 30-degree elevation of the patient’s head, when permissible, and frequent oral care.

Critical Care/Medical Intensive Care Unit

Percent Occurrence of Ventilator-Acquired Pneumonia/1000 Ventilation DaysPercent Occurrence of Ventilator-Acquired Pneumonia/1000 Ventilation Days

0

1

3

2

4

5

2004 2005 2006 2007

VAP Threshold


Unit Acquired RateHospital Acquired Rate

2007

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

PercentPercent

0

40

100

80

60

20

5/166/16

13/18

17/18

7/17 7/17

10/18

14/18

Unit-Acquired Pressure Ulcers in the Surgical Intensive Care UnitPatients in the Surgical Intensive Care Unit are at high risk for skin breakdown for many reasons, including weakened immune system, complex surgery, poor nutrition, excessive skin moisture, confusion, decreased activity and advanced age. Skin care initiatives implemented in 2007 decreased the incidence of skin impairment.

Initiatives:

• Upgraded therapeutic bed surfaces

• Collaborative weekly skin care rounds

• Nurse attendance in quarterly skin care classes

• Hosting monthly skin care in-services

• Routine discussion of skin care issues during shift report

• Skin care plan implementation through shared governance activities

• Revision of skin care documentation

• Reviewing skin care issues at monthly staff meetings

• Purposeful audits of admission sheets completion with regards to skin care

• Developed motto: “Every Nurse is a Skin Care Nurse”

Critical Care/Surgical Intensive Care Unit

2003Year Cleveland Clinic was first designated a Magnet Hospital

Outcomes 2007 24

Percent Left without Being SeenPercent Left without Being Seen

0

7

2

1

4

5

3

6


2006 2007Arrival to Assessment by Healthcare Provider, MinutesArrival to Assessment by Healthcare Provider, Minutes

024

10151416

68


2006 2007

Triage (Initial Assessment) Process Improvement PlanA triage process improvement plan was initiated in January 2007. Prior to this, patients were triaged in the triage area and sent to an available exam room. Now, patients are sent directly into an exam room, when available, and triage and registration are performed at the bedside.

We developed a “Triage Plus” area to facilitate patient flow when the department is at full capacity. Triage guidelines are followed and lab work and tests are initiated.

In 2007, 52,576 patients arrived in the Emergency Department for treatment. Changes we made have resulted in a decrease in the number of people who leave prior to assessment and care (left figure). Additionally, the plan decreased the time from arrival to assessment by a healthcare provider (physician or nurse; right figure).

Emergency Services Institute


05

1015202530354045

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Decn=197 n=184 n=203 n=181 n=194 n=184 n=171 n=178 n=218 n=227 n=195 n=158

Length of Stay Hours, 2007Length of Stay Hours, 2007

Non Intensive Care PatientsIntensive Care Patients

Program Initiated

Length of Stay in the Hospital Transfer Unit Triage (Initial Assessment) Process Improvement PlanOn September 2006, the Hospital Transfer Unit opened to provide additional beds for short-term use, facilitate patient access and serve as an intake area where tertiary referrals could be triaged to intensive care or regular units.

To manage length of stay in the Hospital Transfer Unit, a throughput initiative was started in September 2007. A Surgical Intensive Care Unit physician rounds daily with a RN unit leader and discusses the patient plan of care, possible disposition, current length of stay and special care issues. The throughput nurse uses this information to prioritize transfer of patients to the appropriate unit.

This initiative resulted in a marked reduction in the Hospital Transfer Unit length of stay (graph).

1,648Number of people coming to

the Emergency Department

with non-cardiac chest pain

as the admitting diagnosis;

representing 3% of total

volume in 2007

Outcomes 2007 26

PainMedicine

Ear Plugs Eye Shields GuidedImagery

Percent of Patients using Strategies to Promote SleepPercent of Patients using Strategies to Promote Sleep

0

100

80

60

40

20

Strategies to Promote Sleep after Open Heart SurgeryIn 2006, Cleveland Clinic introduced a patient admission kit with personal items thought to be needed during a hospital stay, including items thought to decrease exposure to noise and promote sleep at night:

• Guided Imagery Tapes

• Earplugs

• Eye Shields

In 2007, 149 patients participated in nursing research to evaluate the use of sleep strategies after open heart surgery during recovery on a step down/telemetry floor.

We found that patients did not routinely utilize sleep-promoting items provided in the admission kit; they preferred pain control (Figure).

New and innovative ways to promote sleep after open heart surgery are needed.

Heart & Vascular Institute


Percent of Patients Citing the Noise Factors Below as Limiting SleepPercent of Patients Citing the Noise Factors Below as Limiting Sleep

50

100

90

80

70

60

OverheadPaging

Alarms onEquipment

Talking inhallways

Noise Factors that Limit Nighttime SleepHigh noise levels are a common concern on nursing floors, especially at night when patients are trying to sleep.

Lack of sleep due to noise may decrease patient satisfaction with the hospital experience and limit overall recovery.

Learning the predictors of nighttime noise is the first step in developing interventions, as sound may be perceived as bothersome based on personal characteristics or external factors (nurses, equipment, etc.).

In 2007, 149 postoperative surgical patients completed surveys of noise factors that impaired nighttime sleep. The top three noise factors (Figure) were modifiable factors that healthcare personnel can impact through noise reduction interventions.

Outcomes 2007 28

0

60

50

40

30

20

10

Average Number of Patients Per Week Discharged Homeby Discharge Lounge PersonnelAverage Number of Patients Per Week Discharged Homeby Discharge Lounge Personnel

n=1020

n=2963

Utilization of the Discharge Lounge Personnel to Aid in Discharge Home of Cardiac Step-Down and Telemetry Unit PatientsBy utilizing the Discharge Lounge and/or Discharge Lounge personnel to transfer a patient from floor to home, beds are freed up for incoming patients from the Emergency Department, other hospitals, outpatient clinics and Intensive Care Units, improving hospital throughput.

In 2007, unit managers identified opportunities to improve utilization of Discharge Lounge facilities and personnel and implemented action plans, resulting in a 180 percent increase in the volume of patients utilizing the discharge lounge or personnel in transfers per week (Figure), compared to 2006.

3,439

9,078

2,262Number of open heart

surgeries, cardiac

catheterizations and

interventional cardiac

procedures respectively,

performed by the Heart

and Vascular Institute

team in 2007


2004 2005 2006 2007

Percent Patient SatisfactionPercent Patient Satisfaction

0

100

80

60

40

20

n=237

n=196 n=221

n=332

Overall Quality ofCare - % Excellent

Nursing Staff Treated You with Courtesy and Respect - % Excellent

Changing the Model of Care on the Transplant Special Care Unit to Improve Patient SatisfactionIn second quarter of 2006, a team model of cCare was introduced on the Transplant Special Care Unit. The revised team of a registered nurse, licensed practical nurse and patient care nursing assistant provides more caregivers at the bedside to meet patient needs compared to the old model of an RN and patient care nursing assistant.

By January 2007, a full complement of LPNs was available.

The new model was associated with an increase in patient satisfaction (Figure), specifically in:

• Overall quality of care

• Nursing staff exhibiting courtesy and respect

64 / 72Number of heart

and lung transplants

completed in 2007,

respectively

Outcomes 2007 30

PercentPercent

0

10

20

30

40

Constipation Stool Softener Use

2006, N = 64 2007, N = 68

Constipation Prevention in Geriatric PatientsConstipation is a common and painful condition affecting many hospitalized geriatric patients.

Nursing care directed at detection, prevention and treatment of this condition can impact an older person’s hospital experience.

Beginning in 2006, Internal Medicine Unit staff developed a comprehensive constipation program aimed at improved documentation and staff awareness.

Chart audits were conducted and an educational poster was created for nursing staff to increase awareness of the program.

• In 2007, we found an increase in use of stool softeners and a decrease in constipation.

Medicine

35Number of new graduates

in Cleveland Clinic’s

inaugural on-site program

for associate degrees in

nursing and radiography.

Cleveland Clinic partnered

with Cuyahoga Community

College for the program

in an effort to reduce

healthcare worker

shortages and create

new opportunities for

employees.


Percent Compliance with Documentation in 48 HoursPercent Compliance with Documentation in 48 Hours

0

100

80

60

40

20

Jan Feb Mar Apr May Jun JulAug Sep Oct

20072006

Nov Dec Aug Sep Oct Nov Dec

n=44

n=19

n=27 n=26

n=35

n=37

n=11

n=26

n=21

n=33

n=32

n=25

n=26

n=21 n=33

n=32

n=25

Patient Education Documentation Improvement in Internal MedicinePatient education is a vital component of nursing practice.

A busy internal medicine unit was able to improve and sustain consistent patient education documentation within 48 hours of admission by:

• One-on-one staff training on how to document patient education in the electronic medical record

• Reorganization of and increased awareness surrounding available educational materials

• Positive reinforcement and/or remediation

Outcomes 2007 32

PercentPercent

0

100

80

60

40

20

2006 2007

n=1426 n=1708

TargetLongShortOther

0

3.5

2.5

2.0

1.5

1.0

0.5

2006 2007

Percent of Catheter Tips in the Internal Jugular VeinPercent of Catheter Tips in the Internal Jugular Vein

n=34

n=17

Peripherally Inserted Central Catheter TeamCleveland Clinic’s nurse-based Peripherally Inserted Central Catheter Team places the majority of peripherally inserted central catheters.

The procedure is completed at the bedside.

The tip of the catheter should be placed in the caval-atrial junction of the subclavian vein for optimal catheter functioning and prevention of complications.

Each patient is custom-measured to optimize target placement of the catheter tip.

Team members examined the accuracy of tip placement after insertion to assess their performance. Their goal is to maximize the number of catheters with tips at target position.

Results: Peripherally Inserted Central Catheter Tip Position • Target tip position increased from 64% in 2006 to 75% in 2007.

• Tip location in the internal jugular vein was reduced by more than 50% in 2007, compared with 2006.

124,840Number of dollars spent

on professional organization

memberships for nurses

in 2007

Surgical Floors


Average Number of Patients Per MonthAverage Number of Patients Per Month

0

100

200

300

400

500

2005 2006 2007

Discharge Lounge staff assist patients with:

• Scheduling follow-up appointments

• Filling prescriptions

• Reviewing home-going instructions

• Arranging for transportation

In 2007, the Discharge Lounge use was expanded to include:

• Outpatients waiting between appointments

• Pre-admission patients coming from our hospital lobby

The Discharge Lounge creates a comfortable and convenient place for hospitalized patients who have been discharged and are awaiting transportation home.

Utilization of the Discharge Lounge

Understanding and appreciating the value of the Discharge Lounge by the inpatient nursing units is essential.

In August 2007, efforts were made to increase staff awareness of the capabilities of the lounge and to promote its use.

• Increased awareness led to a 103% increase in average monthly utilization of the discharge lounge by hospital patients awaiting discharge home.

Use of the Discharge Lounge by hospital patients awaiting discharge home is an important aspect of hospital efficiency, since the lounge serves to meet patient needs prior to discharge and improves turnaround time for getting a new patient into the vacated bed.0

600

500

400

300

200

100

January - July August - December2007

n=2657

Average Number of Patients Per MonthAverage Number of Patients Per Month

n=1824

16Number of recliners in

the Discharge Lounge,

creating a comfortable

and relaxing environment

for patients awaiting

transportation home

Outcomes 2007 34

Percent CompliancePercent Compliance

0

100

20

40

80

60

2006, N = 507 2007, N = 725


Percent of ResponsesPercent of Responses

0

10

20

60

30

40

50

Excellent Very Good Good Fair Poor

N = 3078

Family Updates from PersonnelTimely family communication regarding a patient’s status after surgery may relieve family members’ anxiety. Improved communication fosters improved family satisfaction.

Overall Quality of CarePatients undergoing an outpatient surgical procedure and discharged home from the Same Day Surgery Unit receive a post discharge phone call within 48 hours to determine the overall quality of nursing care received during surgery and recovery.

Surgical Services/Operating Room and Post Anesthesia Care Unit

In 2007, the number of family members receiving an update within 2 hours of the patient’s arrival to Post Anesthesia Care Unit increased compared to 2006.

In 2007, a majority of patients rated the “Overall Nursing Care and Service” in Same Day Surgery as excellent.


Number of Patients Boarding in thePost Anesthesia Care UnitNumber of Patients Boarding in thePost Anesthesia Care Unit

0

300

100

50

150

250

200

Boarders 2006 Boarders 2007


34,400Number of surgical cases

performed in the operating

rooms of Cleveland Clinic’s

main campus; 28% were

outpatient surgeries.

Post Anesthesia Care Unit Role in Throughput and CollaborationIn 2006, the Post Anesthesia Care Unit experienced a high volume of boarders (non-surgical patients using the bed space and nursing care services) primarily due to the full capacity of hospital in-patient beds.

To address this concern, a multidisciplinary team developed a plan to improve the placement of our postoperative patients, as well as patients being hospitalized from our Emergency Department, direct admissions and transfers from other institutions.

Nursing also worked with the Surgery Institute to regulate our Same Day Surgery admits.

A noticeable improvement occurred by February 2007 and was sustained throughout 2007.

This collaborative effort directly improved patient, family and nurse satisfaction.

Outcomes 2007 36

QDM* DatabaseCleveland ClinicMean ScoreMean Score

0

10

8

6

4

2

2006(n=58,007)

2007(n=51,026)

* QDM=Quality Data Management, a national patient experience survey vendor

QDM DatabaseCleveland ClinicMean ScoreMean Score

0

10

8

6

4

2

2006(n=60,529)

2007(n=53,465)

Overall Rating of Care 0 worst - 10 best scale

Overall Rating of Nursing Staff 0 worst - 10 best scale

OutpatientWe ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we are providing excellent care, we are committed to continuous improvement.

Patient Experience



0

10

8

6

4

2

2006(n=3,556)

2007(n=2,215)


0

10

8

6

4

2

2006(n=3,594)

2007(n=2,289)

Overall Rating of Pediatric Outpatient Care 0 worst - 10 best scale

Pediatric Outpatient Problems with Post Visit Instructions

Yes, Definitely

Definitely Not

Yes, Somewhat

Outcomes 2007 38

0

20

40

60

100

Cleveland Clinic

Total Cleveland Clinic Survey Respondents = 4725

HCAHPS National Average

Percent “9” or “10”Percent “9” or “10”

80

0

20

40

60

100

Cleveland Clinic HCAHPS National Average

Percent “Yes, definitely”Percent “Yes, definitely”

80

Total Cleveland Clinic Survey Respondents = 4725

Overall Rating of Care 0 worst - 10 best scale October 2006 - June 2007

Would Recommend Facility October 2006 - June 2007

Inpatient - Cleveland ClinicWith the support of the Center for Medicare and Medicaid Services (CMS) and its partner organizations, the first national standard patient experience survey was implemented in late 2006. Adult medical, surgical, and obstetrics and gynecology patients treated at acute care hospitals across the country are included in the survey. Results collected for initial public reporting, published on www.hospitalcompare.gov in March 2008, are shown here.

Nursing Institute39

InnovationsNursing WellnessNursing Wellness reaches out to nurses on the main campus and regional sites. The focus is to add wellness to everything we do. Here are some of the programs and efforts that were created in 2007 through Nursing Institute wellness activities:

• Refresh Center: The center was created for nursing employees to rest for about 20 minutes before leaving work after a night shift. The Center offers a shake awake alarm; access to caffeinated beverages; ear plugs; and a comforting, warm washcloth/towel.

• Refresh Breaks: These provide “time out” for employees to receive a 10-minute Reiki session at no charge.

• Sanctuary Spaces: quiet, private spaces with a massage chair give nurses the opportunity to relax and recharge during their shift without leaving their units.

• Wellness Orientation: New employees to the Nursing Institute are introduced to personal wellness and self care during nursing orientation.

• Energized, the theme of the wellness modules for 2007 and 2008, involved the creation of the “Green Apple Corp” to increase awareness of staff around positive wellness behaviors such as healthy eating, drinking enough water, asking for help or taking a time out.

The Red Carpet Program, Attracting and Engaging Nurses Every Step of the Way• A welcome program for the more than 1,000 student nurses who affiliate with Cleveland Clinic each year.

• Students are greeted at their initial visit by a liaison from Nursing Education, who welcomes them and gives them a comprehensive Red Carpet Packet that includes a welcome letter from the Chief Nursing Officer, a DVD introduction to the Nursing Institute, student clinical rotation evaluation forms, information on student shift opportunities, helpful hints if applying for a job online and more.

40Outcomes 2007

Career Coaching for Nurses

Career Coaches, a retention program, utilizes experienced Cleveland Clinic nurses to address nursing issues.

• The coaches hear issues of nurses and identify and address their needs quickly and, if requested, privately.

• They survey new nurses at 3 months, 6 months, 12 months and 18 months of employment to learn what is working to facilitate retention after hire.

• A Senior Nurse Retention Council was formed to address the unique career needs of experienced nurses.

Cleveland Clinic Employees Become Nurses

A U.S. Department of Labor grant aimed at alleviating healthcare worker shortages and creating career opportunities for incumbent employees was awarded to Cleveland Clinic and Cuyahoga Community College.

This partnership provided employees of the Cleveland Clinic Health System the opportunity to attend an on-site nursing program at their place of employment. An unprecedented piece in this collaboration was the use of Cleveland Clinic nurses as clinical adjunct faculty. This sharing of the educational process served to ameliorate the burden that finding additional nursing faculty placed on the community college.

Student evaluations of the clinical experiences were extremely positive. Not only did our employees recognize our nurses as clinical scholars, they also stated they felt a sense of pride and belonging to the Cleveland Clinic nursing community.

Nursing Institute41

Deans’ Roundtable Faculty InitiativeThe shortage of nursing school faculty consistently surfaces as the leading problem facing schools of nursing. The Deans’ Roundtable Faculty Initiative was formed to address the faculty shortage aggressively. It is a collaborative effort between Cleveland Clinic and participating schools of nursing.

Key deliverables of this initiative:

• identify, recruit and support area nurses interested in serving as faculty

• offer faculty development programs for nursing faculty in Northeast Ohio

• strengthen relationships between service and education in Northeast Ohio

Faculty Allocation Tool: a website that matches potential faculty with available teaching opportunities. Nurses independently manage their profiles and faculty work commitments.

The website:

• is open to all eligible nurses.

• includes the continuum of teaching venues (i.e., clinical, classroom, skills lab, preceptor, research).

• allows all participating schools to recruit potential faculty.

Outcomes 2007 42

Boot Camp for New FacultyThis is an introductory course for new faculty, standardized across all participating schools. Boot Camp is offered twice each academic year. It is taught by faculty from participating Schools of Nursing.

Annual Faculty Development Programs: Schools of Nursing and Cleveland Clinic collaboratively sponsor an annual faculty development program, sharing expenses and minimizing cost to attendees.

Nursing Institute43

A Family Affair in the Neonatal Intensive Care UnitFamilies of critically ill infants want to spend as much time as possible at the baby’s bedside. Many families travel long distances to visit, so Neonatal Intensive Care Unit (ICU) nurses created a new opportunity for family instruction.

“Video on Demand” is an online resource that allows family members in the Neonatal ICU to view educational videos right from their baby’s bedside computer. Nurses can download educational videos important for family members’ education.

Using disposable earphones decreases excess ambient noise in the Neonatal ICU. In addition, this educational venue provides nurses the ability for immediate follow-up regarding family member understanding of instructions and facilitates questions by family members about their baby’s progress and care.

Family-Centered RoundsCommunication is a critical element in safe patient care.

A multidisciplinary team in the Pediatric Institute & Children’s Hospitalthat includes nurses, pediatric residents, hospital medicine staff and unit secretaries collaborated to improve patient safety through use of Family-Centered Rounds.

Measurable outcomes of Family-Centered Rounds include:

• improved patient/family satisfaction

• improved length of stay and timeliness of discharge

• reduced medication prescribing errors

• improved effectiveness of communication among caregivers

• timely medication reconciliation

• active involvement of patients and their families in the patient’s plan of care

Outcomes 2007 44

New KnowledgeJournal Articles

Albert N. Non-ST segment elevation acute coronary syndromes: Treatment guidelines for the nurse practitioner. J Am Acad Nurse Pract. 2007 Jun;19(6):277-289.

Albert NM. Heart failure with preserved systolic function: giving well-deserved attention to the “other” heart failure. Crit Care Nurs Q. 2007 Oct;30(4):287-296.

Albert NM, Zeller RA. Development and testing of the survey of illness beliefs in heart failure tool. Prog Cardiovasc Nurs. 2007;22(2):63-71.

Albert NM. Switching to once-daily evidence-based {beta}-blockers in patients with systolic heart failure or left ventricular dysfunction after myocardial infarction. Crit Care Nurse. 2007 Dec;27(6):62-72.

Albert NM, Buchsbaum R, Li J. Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors. Patient Educ Couns. 2007 Dec;69(1-3):129-139.

Albert NM, Fonarow GC, Abraham WT, Chiswell K, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Sun JL, Yancy CW, Young JB. Predictors of delivery of hospital-based heart failure patient education: a report from OPTIMIZE-HF. J Card Fail. 2007 Apr;13(3):189-198.

Coughlin RM. Recognizing ventricular arrhythmias and preventing sudden cardiac death. American Nurse Today. 2007 May;2(5):38-44.

Dumpe ML, Kanyok N, Hill K. Use of an automated learning management system to validate nursing competencies. J Nurses Staff Dev. 2007 Jul;23(4):183-185.

Erwin-Toth P. Skin changes from radiation therapy. J Wound Ostomy Continence Nurs. 2007 Sep;34(5):546.

Faiman B. Clinical updates and nursing considerations for patients with multiple myeloma. Clin J Oncol Nurs. 2007 Dec;11(6):831-840.

Fielden NM, Leavitt V. Update on antibiotics for ED pneumonia patients. ED Nursing. 2007 Jul;10(9):106-107.

Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Sun JL, Yancy C, Young JB. Carvedilol use at discharge in patients hospitalized for heart failure is associated with improved survival: An analysis from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am Heart J. 2007 Jan;153(1):82.e1-82.e11.

Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy C, Young JB. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70.

Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Sun JL, Yancy CW, Young JB. Prospective evaluation of beta-blocker use at the time of hospital discharge as a heart failure performance measure: results from OPTIMIZE-HF. J Card Fail. 2007 Nov;13(9):722-731.

Fonarow GC, Abraham WT, Albert NM, Gattis Stough W, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy CW, Young JB. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med. 2007 Jul 23;167(14):1493-1502.

45Number of active

Institutional Review

Board approved

research studies the

Nursing Institute had

in various stages of

progress in 2007

27Number of research

projects the Nursing

Institute completed in

2007. These led to 10

presentations and 15

manuscripts.

Nursing Institute45

Fonarow GC, Stough WG, Abraham WT, Albert NM, Gheorghiade M, Greenberg BH, O’Connor CM, Sun JL, Yancy CW, Young JB. Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry. J Am Coll Cardiol. 2007 Aug 21;50(8):768-777.

Fonarow GC, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, Mehra M, O’Connor CM, Reynolds D, Walsh MN. Improving the use of evidence-based heart failure therapies in the outpatient setting: the IMPROVE HF performance improvement registry. Am Heart J. 2007 Jul;154(1):12-38.

Gheorghiade M, Abraham WT, Albert NM, Gattis Stough W, Greenberg BH, O’Connor CM, She L, Yancy CW, Young J, Fonarow GC. Relationship between admission serum sodium concentration and clinical outcomes in patients hospitalized for heart failure: an analysis from the OPTIMIZE-HF registry. Eur Heart J. 2007 Apr;28(8):980-988.

Greenberg BH, Abraham WT, Albert NM, Chiswell K, Clare R, Stough WG, Gheorghiade M, O’Connor CM, Sun JL, Yancy CW, Young JB, Fonarow GC. Influence of diabetes on characteristics and outcomes in patients hospitalized with heart failure: A report from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am Heart J. 2007 Oct;154(4):647-654.

Gresko G. On the road... Our magnet journey. AAACN Viewpoint. 2007 Mar-Apr;29(2):3-6.

Hall D. Detect compartment syndrome in time. American Nurse Today. 2007 Jul;2(7):42.

Hernandez AF, Fonarow GC, Liang L, Al-Khatib SM, Curtis LH, LaBresh KA, Yancy CW, Albert NM, Peterson ED. Sex and racial differences in the use of implantable cardioverter-defibrillators among patients hospitalized with heart failure. JAMA. 2007 Oct 3;298(13):1525-1532.

Hill KM. Surgical repair of cardiac valves. Crit Care Nurs Clin North Am. 2007 Dec;19(4):353-360.

Hocevar BJ. Obstructive uropathy secondary to pneumoperitoneum in a patient with ileal conduit. J Wound Ostomy Continence Nurs. 2007 Nov;34(6):680.

Klein DG. Current trends in cardiac transplantation. Crit Care Nurs Clin North Am. 2007 Dec;19(4):445-460.

Lewandowski W, Morris R, Draucker CB, Risko J. Chronic pain and the family: theory-driven treatment approaches. Issues Ment Health Nurs. 2007 Sep;28(9):1019-1044.

Malbasa T, Kodish E, Santacroce SJ. Adolescent adherence to oral therapy for leukemia: a focus group study. J Pediatr Oncol Nurs. 2007 May;24(3):139-151.

McNeal R, Schmeida M, Hale K. E-disclosure laws and electronic campaign finance reform: Lessons from the diffusion of e-government policies in the States. Gov Inf Q. 2007 Apr;24(2):312-325.

Mitchell RL. Migraine headaches come to camp. CompassPoint. 2007 Sep;17(3):11-14.

Modic MB, Harris R. Masterful precepting: Using the BECOME method to enhance clinical teaching. J Nurses Staff Dev. 2007 Jan;23(1):1-9.

Nieman CT, Manacci CF, Super DM, Mancuso C. In reply: Use of the Broselow tape may result in the underresuscitation of children. Acad Emerg Med. 2007 May;14(5):501-502.

Parker BM, Henderson JM, Vitagliano S, Nair BG, Petre J, Maurer WG, Roizen MF, Weber M, DeWitt L, Beedlow J, Fahey B, Calvert A, Ribar K, Gordon S. Six sigma methodology can be used to improve adherence for antibiotic prophylaxis in patients undergoing noncardiac surgery. Anesth Analg. 2007 Jan;104(1):140-146.

Paschke SM. Career coaches for nursing: a strategy for increasing your ROI. Nurs Econ. 2007 Jul;25(4):238-240.

Schmeida M, McNeal R, Mossberger K. Policy determinants affect telehealth implementation. Telemed J E Health. 2007 Apr;13(2):100-107.

Schmeida M, McNeal RS. The telehealth divide: disparities in searching public health information online. J Health Care Poor Underserved. 2007 Aug;18(3):637-647.

Schmeida M. Rural health policy: telehealth to bridge the rural-urban health care divide. AAACN Viewpoint. 2007 Sep-Oct;29(5):18-19, 8.

Stafford JR, Emery DM. Getting the patient out of the hospital on parenteral nutrition: Catheter selection, assessment, and education. Support Line. 2007 Jun;29(3):3-7.

Tabone G, Shainoff J. Finally -- the perfect resource for triage nurses! AAACN Viewpoint. 2007 Jan-Feb;29(1):12.

Weiss PA. Can cancer be diagnosed with a blood test during routine examinations? Clin J Oncol Nurs. 2007 Dec;11(6):940-941.

Williams C. Telehealth nursing practice. AAACN Viewpoint. 2007 Jan-Feb;29(1):12.

Woodman R, Radzyminski S. Women’s perception of life following breast reduction: a phenomenological study. Plast Surg Nurs. 2007 Apr-Jun;27(2):85-92.

Young CM, Albert NM, Paschke SM, Meyer KH. The ‘Parent Shift’ program: Incentives for nurses, rewards for nursing teams. Nurs Econ. 2007 Nov-Dec;25(6):339-344.

Outcomes 2007 46

Book ChaptersAlbert NM. Managing a heart failure clinic. In: McCarthy PM, Young JB, eds. Heart failure : a combined medical and surgical approach. Malden, MA: Blackwell Futura; 2007:99-114.

Halper J, Namey MA. Infusion therapies in multiple sclerosis : nursing implications. In: Halper J, ed. Advanced concepts in multiple sclerosis nursing care. 2nd ed. New York, NY: Demos; 2007:79-89.

Klein DG. From novice to expert: CNS competencies. In: McKinley MG, ed. Acute and critical care clinical nurse specialists: Synergy for best practices. St. Louis, MO: Saunders; 2007:11-28.

Levien MG, Gravette J, Hilden JM. Principles of chemotherapy. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:50-53.

Lupica K, Ditz G. Nursing considerations. In: Barnett GH, ed. High-grade gliomas: diagnosis and treatment. Totowa, NJ: Humana Press; 2007:283-300.

Manacci CF. Neurologic emergencies. Transport certification review manual II. Greenwood Village, CO: Air & Surface Transport Nurses Association; 2007:79-81.

McNeal R, Schmeida M. Electronic campaign finance reform in the American states. In: Anttiroiko AV, Malkia M, eds. Encyclopedia of digital government. Hershey, PA: Idea Group Reference; 2007:624-628.

Namey MA. Promoting adherence to complex protocols. In: Halper J, ed. Advanced concepts in multiple sclerosis nursing care. 2nd ed. New York, NY: Demos; 2007:91-100.

Schmeida M, McNeal R. The telehealth divide. In: Anttiroiko AV, Malkia M, eds. Encyclopedia of digital government. Hershey, PA: Idea Group Reference; 2007:1524-1528.

Nursing Institute47

Leadership Team

Chief Nursing Officer and Chair, Nursing InstituteClaire Young, RN, MSN, MBA

Associate Chief Nursing OfficerDebra Albert, RN, BSN, MBA, CNAA; Clinical Michelle Dumpe, RN, MS, PhD Education & Professional Practice Development Dawn Gubanc, RN, MSN, CNAA Strategic Planning and Business Development Susan Paschke, RN, MSN, CNAA; Operations

Nursing Quality DirectorLuann Capone, RN, MSN, APN, BC, MPA, CPHQ

Finance DirectorJames Massey, CPA

Assistant AdministratorsBrian Monter, RN, MSN, MBA Shirin Rastgoufard, BA, MBA

Ambulatory Nursing DirectorNancy May, RN-C, MSN

Ambulatory Surgery Centers DirectorDeborah Atsberger, RN, MSN, CPAN

Advanced Practice Nursing DirectorJanet Fuchs, RN, MSN, CNAA

Pediatric Institute & Children’s Hospital DirectorJane Burke, RN, BSN

Emergency Services/Critical Care DirectorBarbara Morgan, RN, MSN, CNA

Heart & Vascular Institute DirectorK. Kelly Hancock, RN, BSN Shannon Pengel (Assistant), RN, BSN

Informatics DirectorTeresa Wimms, RN

Medicine & Cancer Center DirectorBarbara Reece, RN, MSN, CS

Neurological & Behavioral Institute DirectorKimberly Hunter, RN, MSN, MBA, E-BC

Nurse Recruitment DirectorLois Bock, RN, BS

Nurse Accreditation SpecialistDana Wade, RN, MSN

Regional Medical Practice Nursing DirectorCathy Lutz, RN, MSN

Research & Innovation Director Nancy Albert, RN, PhD, CCNS, CCRN, CNA, FAHA, FCCM

Surgical Acute Care DirectorMaureen Palmer, RN, BSN, MBA, CRRN

Surgical Services DirectorBarbara Wilson, RN, MSN, CNOR, CNAA Barbara Fahey (Assistant), RN

World Class Service DirectorCarol Santalucia, BS, MBA

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Contact Information Institute LocationsNursing Administration

216.444.2403

RN and LPN Nurse Recruitment

Toll-free 866.219.7149

On the Web at clevelandclinic.org/nursing

Main Campus

9500 Euclid Ave./P32 Cleveland, OH 44195

RN and LPN Nurse Recruitment

Cleveland Clinic Administrative Campus Building 3 3050 Science Park Drive Beachwood, OH 44122

Additional Contact Information General Information

216.444.2200 Hospital Patient Information

216.444.2000 Patient Appointments

216.444.2273 or 800.223.2273 Special Assistance for Out-of-State Patients

Complimentary assistance for out-of-state patients and families

800.223.2273, ext. 55580, or email [email protected] International Center

Complimentary assistance for international patients and families

800.884.9551 or 001.631.439.1578 or visit clevelandclinic.org/ic Cleveland Clinic in Florida

866.293.7866

For address corrections or changes, please call 800.890.2467

Nursing Institute49

Cleveland Clinic Overview Online Services

Cleveland Clinic, founded in 1921, is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Today, 1,800 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties, annually recording more than 3 million patient visits and more than 70,000 surgeries.

In 2007, Cleveland Clinic restructured its practice, bundling all clinical specialties into integrated practice units called institutes. An institute combines all the specialties surrounding a specific organ or disease system under a single roof. Each institute has a single leader and focuses the energies of multiple professionals onto the patient. From access and communication to point-of-care service, institutes will improve the patient experience at Cleveland Clinic.

Cleveland Clinic’s main campus, with 37 buildings on 140 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs and facilities. Cleveland Clinic also operates 14 family health centers; eight community hospitals; two affiliate hospitals; a 150-bed hospital and clinic in Weston, Fla.; and health and wellness centers in Palm Beach, Fla., and Toronto, Canada. Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to open in 2011.

At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based research. Total annual research expenditures exceed $150 million from federal agencies, non-federal societies and associations, and endowment funds. In an effort to bring research from bench to bedside, Cleveland Clinic physicians are involved in more than 2,400 clinical studies at any given time.

In September 2004, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University opened and will graduate its first 32 students as physician-scientists in 2009.

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1 since 1995.

For more information about Cleveland Clinic, visit clevelandclinic.org.

eCleveland CliniceCleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second medical opinions to patients around the world; personalized medical record access for patients; patient treatment progress for referring physicians (see below); and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

DrConnectOnline Access to Your Patient’s Treatment Progress

Whether you are referring from near or far, DrConnect can streamline communication from Cleveland Clinic physicians to your office. This online tool offers you secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit eclevelandclinic.org or email [email protected].

MyConsultMyConsult Remote Second Medical Opinion is a secure online service providing specialist consultations and remote second opinions for more than 600 life-threatening and life-altering diagnoses. The MyConsult service is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

9500 Euclid Avenue, Cleveland, OH, 44195

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

© The Cleveland Clinic Foundation 2008

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Please visit us on the Web at clevelandclinic.org.