Thursday, September 17, 2009

Vickie's Research Corner

View my guestbookCan you believe it? Fall is here and the weather is changing. Things at St. Joseph are changing just like the seasons and the new buzz word is Evidence-Based Practice (EBP). As we continue in our journey as a Magnet organization, EBP is pushing its way into the practice of nurses throughout the hospital. Over the past year I have begun to introduce you to our new Clinical Nurse EBP Experts. These are Clinical Nurse III/IV nurses who took an intensive 4 day class to become more familiar with EBP and how this impacts their practice as well as yours. This issue I would like to introduce you to Rashna Thakur and Ellen Gruwell.
Rashna is Clinical Nurse III and works in the Pediatric Renal Center. She has been at this hospital since 1996. She became a Clin III 2 years ago. When asked why she wanted to become an EBP expert she responded that she had no clue what a Clinical Nurse EBP Expert initially was and was encouraged by Ann Marie Keefer-Lynch to apply for the program. Initially when taking the course she felt a rookie in the crowd because everyone else knew about EBP. After taking the course she realized that EBP was great. Knowledge was eye opening! She learned what EBP is and who does it. She now understands how to look for research and apply EBP at the bedside. Rashna feels much more aware of evidence and how we use it. She now makes changes in her practice based on evidence, not tradition.
Taking the class encouraged her to accomplish several goals. Now nurses are cross-training from primarily pediatrics to adults and she helped create the new policy based on EBP. She was able to take what she learned and put it into practice. Rashna was no longer the rookie in the crowd who didn’t understand EBP!
Our second Clinical Expert is Ellen Gruwell. She has been a nurse in the St. Joseph Health system since 1981. Initially she worked for St. Jude and then in 1987 came to SJH. Currently she works in Labor and Delivery as a Clinical Nurse III. Ellen felt that her masters program at California State University Fullerton and meeting Dana Rutledge made the biggest difference in her life for wanting to learn more about EBP and Research, so she decided to become a Clinical Expert.
For Ellen, she learned that there is a lot of buy in for EBP from nursing. It seems that since she has become an expert she is getting the “lingo” out there and the nurses are starting to change their practice and base their decisions on EBP. Her own practice has changed significantly because she is now more excited about potential research that can be done in Women’s Health Services. She feels nursing is a science and needs to be based in science!
She is now looking at car seats a late preterm infant safety when they go home. She is also interested in identifying how nurses cope in labor and delivery.
Both nurses were from very different areas but both were changed by the world of evidence-based practice and both are changing practice at the bedside!

Wednesday, September 16, 2009

Our Magnet Journey to Redesignation

The Magnet Recognition Program is the nation’s highest honor for nursing and recognizes excellence in Leadership, Practice, and Patient Outcomes. This prestigious award is administered by the American Nurses Credentialing Center (ANCC), who provides individuals and organizations throughout the nursing profession with the resources they need to achieve practice excellence.

To achieve Magnet status, a hospital must demonstrate a culture of excellence in nursing care as well as sustain and demonstrate the 14 Forces of Magnetism in the practice of nursing. The facility must also foster a nursing environment that is exciting, supportive, and intellectually stimulating.

The Magnet Recognition program focuses on advancing 3 goals within each applicant designee:
* Promoting quality in a setting that supports professional practice
* Identifying excellence in the delivery of nursing services to patients
* Disseminating “best practices” in nursing services

The Next Generation of Magnet:
The 14 Forces of Magnetisms have been redesigned and integrated into The 5 Model Component. This allows for a more focused approach and decreased redundancy. With the 14 Forces as the foundation, the 5 Model Components will be the primary basis for achieving Magnet recognition.
St. Joseph Hospital's Journey continues as we move forward with our gathering of evidence. The Steering Committee and Magnet Ambassadors are currently in the process of accruing and submitting data in their respective component groups. This data will be reviewed and placed in the most appropriate area within the Magnet documents we will submit next year. More to come on our progress...

New article published by staff at St. Joseph Hospital, Orange

Congratulations to Beth (Elizabeth) Winokur, RN, MSN, CEN and John Senteno, RN, MSN, CEN from St. Joseph Hospital in Orange, California on their recent publication in the September issue of Journal of Emergency Nursing.

Winokur EJ, Senteno JM. Guesting area: an alternative for boarding mental health patients seen in emergency departments. J Emerg Nurs. 2009Sep;35(5):429-33. Epub 2008 Oct 17. PubMed PMID: 19748023.
Staff at St. Joseph Hospital, Orange and Children's Hospital of Orange County can read the full text of this article through the link to Journal of Emergency Nursing on the library's website.

Friday, September 04, 2009

The following article appeared in Working Nurse v. 90 Aug 24, 2009 on Nursing Research at St. Joseph's

By Beth Duggan
Have you ever wondered why a procedure is done a certain way? Or why a certain action is taken? If your answer is, “Because it’s always been done that way,” then you’d benefit from a little nursing research.
Not clear on what that is? Let Dana Rutledge, RN, Ph.D., facilitator of the Office of Nursing Research at St. Joseph, enlighten you.
“Nursing research involves multiple steps,” she said. “Thinking of the research question, reviewing the literature to see what else is known on the topic, developing a research plan, seeking approval from the institutional review board, collecting data, analyzing data, and disseminating the results through a written report or poster.”
According to Ms. Rutledge and her assistant, Vickie Morrison, RN, MSN, FNP, this kind of research is important because the results offer a chance to improve patient outcomes. And nurses who stay current about evidence in their area are more likely to use best evidence.A Culture of Inquiry
St. Joseph’s nursing research department started in June 2004 as the hospital began its journey toward magnet status. Lacking a Ph.D.-prepared nurse who could conduct the research, they brought in Ms. Rutledge, who is also a professor in the nursing department at California State University, Fullerton.
Through her facilitation and the work of Ms. Morrison, the research office has, according to the staff, “led to a culture of inquiry, and the desire to base nursing care practices on best evidence.” Inquiring nurses at St. Joseph have been performing both evidence-based practice changes and research, and some have even submitted abstracts to conferences for podium and poster presentations about projects that have been completed.
One such case was a group of nurses in the ambulatory post-anesthesia care unit. Their research found that patients were not fully prepared for their surgical experience, which led to changed materials sent to physicians’ offices and phone calls made to patients before their procedure to help them feel more prepared. The results were presented as a poster at a regional conference.
The two nurses say the biggest challenge in their work has been getting word out that there is a Nursing Research Office, so in 2007 they visited almost all the departments in the hospital that employ nurses to discuss what the Office of Nursing Research does and to find out what questions nurses have about their own practice.
The success of that initiative has bred more success for the office, which means juggling multiple projects at once.
“Right now we have two manuscripts to nursing journals that we submitted with study results, both of which require revisions,” said Ms. Morrison. “We have four newly approved studies that are in the beginning phases of data collection; we have two studies that are ready for data analysis; and the rest are all in the data collection phase. Then there are three groups of nurses who are in the preparation phases.”Evidence-based Blog
In March 2006, Julie Smith, MLS, AHIP, the medical librarian at St. Joseph, wanted to give a unique contribution and enhance the arena of EBP and nursing research. This led her to the Internet, where she developed a blog dedicated to “bringing awareness to current nursing literature, conferences, resources and tutorials.”
The first team nursing blog dedicated to EBP and research, it is full of useful information such as how to read research articles, how to create a poster for dissemination, and new information on EBP. It also gives tips for searching on St. Joseph’s and Childrens Hospital Orange County’s research databases. To date the site has received approximately 71,000 hits, which averages to 102 daily and 3,060 each month.
“Evidence-based practice in nursing is constantly changing with new research and new evidence,” Ms. Rutledge said. “The most important significance for EBP is the fact that nurses are learning how to use evidence at the bedside to improve patient outcomes. EBP provides a solid foundation for nursing to change practice in a manner that is systematic and credible.”
Beth Duggan is the editor of Working Nurse.

Thursday, September 03, 2009

Vitamin D- the new wonder drug??

The September issue of The American Journal of Medicine (Volume 122, Issue 9) has an extensive review of the research on the benefits of Vitamin D. The article notes that over 1/2 of the world's population is Vitamin D deficient. We used to think that Vitamin D was only important for healthy bones but recent research has shown that Vitamin D affects our health in many other ways.
Vitamin D is important in bone health- one study showed that given 800iu/d of Vit D- persons aged 65-85 years of age had 1/3 reduced fracture risk.
Vitamin D is also needed for muscle development and function- one study has shown a 22% decrease in falls related to improved neuromuscular function with Vitamin D supplementation. Vitamin D is found to decrease muscle degeneration and increase reaction time and motor response which also decreases fall and therefore fracture risk.
Vitamin D has also been linked to chronic pain. Numerous studies have tied low levels of vitamin D to persistent musculoskeletal and neuropathic pain. Persons with chronic pain that has no obvious cause should be tested vitamin D deficiency.
Vitamin D is involved in the immune response and autoimmune diseases. Research has found a 40% lower risk of multiple sclerosis in women taking vitamin D supplements. Lupus and rheumatoid arthritis symptoms are more severe in those who are vitamin D deficient.
It seems that Vitamin D influences insulin sensitivity and beta cell function as well. Up to a 60% increase in insulin sensitivity was found in persons with greater than 30ng/ml serum vitamin D levels compared with those that have less than 10ng/ml. One study showed an 80% decreased risk of developing diabetes type 1 in children supplemented with 2000 iu/d of vitamin D in the first year of life. These children were followed for 20 years.
It appears that vitamin D is also involved in brain function. Older adults with low vitamin D levels performed worse on the mini mental status exam and showed more memory problems and depression than those with normal vitamin D levels. One large study found a correlation with depression severity and low vitamin D levels.
Some studies show a decrease in cancer risk and mortality associated with vitamin D. Vitamin D has been found to be antiproliferative, promote cell differentiation, and induce apoptosis, among other anti-cancer properties. Numerous studies have shown benefit in prevention and mortality in colorectal cancer, pharyngeal cancer and leukemia, as well as decreased breast cancer risk and decreased mortality from melanoma.
There is evidence that vitamin D has a role in cardiovascular health. Vitamin D is thought to influence the reticular activating system, vascular calcification, smooth muscle proliferation, and inflammation. Studies suggest that vitamin D deficency is an independent risk factor for myocardial infarction in men. Higher vitamin D levels are shown to decrease vascular calcification. Due to it's potent effect on vascular endothelial cells- vitamin D can lower blood pressure. It also seems to have a role in preventing cardiomyopathy- at least in hemodialysis patients.
All cause mortality is decreased by at least 7% in a meta-analysis of 18 randomized trials of vitamin D supplementation.
What do we do now?
Serum Vitamin D levels can by checked by ordering a 25(OH)D serum analysis. A result of 30ng/ml is considered normal although due to variations in laboratory results the current recommendation is to aim for 35-40ng/ml as an optimum level. Some suggest that all individuals be screened for vitamin D levels.
While we synthesize vitamin D from sun exposure- it is not recommended due to skin cancer risk and photoaging effects on the skin. Oral supplementation in the form of vitamin D3 is most effective. While dosage recommendations vary- from 200IU per day and up- it is safe to take larger doses- so1000-3000IU/d may be recommended in the near future.
Clearly there is overwhelming evidence that vitamin D deficiency is widespread and that suppplementation is inexpensive and highly beneficial. For more information refer to the original article and the 108 references that accompany it.

Cancer Research in Breast Cancer

Cancer Research in Breast Cancer Patients

St. Joseph Hospital performs more clinical trials than any other community hospital in Orange County. And, continued advances in cancer care and prevention are the direct result of participation in clinical trials. National evidence from a wide range of studies suggests that cancer patients diagnosed and treated in a setting of multi-specialty care and clinical research may live longer and have a better quality of life.

As a participant in the NCI Community Cancer Centers Program (NCCCP) Pilot, The Center for Cancer Prevention and Treatment is committed to offering residents of Orange County, Southern California and beyond access to research-based cancer care. By expanding clinical trials and cancer care we hope to make it easier to receive high-quality cancer screening, prevention, treatment and palliative care services.

Clinical trials that are well designed and well executed are the best approach for eligible participants to:

Play an active role in their own health care.
Gain access to new research treatments before they are widely available.
Obtain expert medical care at leading health care facilities during the trial.
Help current and future cancer patients by contributing to medical research.

What are the different types of clinical trials?

Treatment trials test experimental treatments, new combinations of drugs or new
approaches to surgery or radiation therapy.

Prevention trials look for better ways to prevent disease in people who have never had the
disease or to prevent a disease from returning. These approaches may include medicines,
vaccines, vitamins, minerals or lifestyle changes.

Diagnostic trials are conducted to find better tests or procedures for diagnosing a particular
disease or condition.

Screening trials test the best way to detect certain diseases or health conditions.

Quality of Life trials (or Supportive Care trials) explore ways to improve comfort and the
quality of life for individuals with a chronic illness.

As the Nurse Navigator for the Breast Program, I am excited to announce that the Research department at the Center for Cancer Prevention and Treatment has recently opened the 9th and 10th clinical trial for breast cancer patients. It is part of my responsibility as the Nurse Navigator for the Breast Program to serve as a reliable source of information about available research trials. I also serve as a vital link for cancer research by demonstrating familiarity with available program-specific trials, the associated eligibility and exclusion criteria, and the informed consent content and process. I assist the Research Department with communication and coordination of required research information, as needed and provide routine updates on patient status with the managing physician and the Cancer Research Department.

The following are a list of the clinical trials we have available at this time:

NSABP B-40 (Neo-Adj): A Randomized Phase III Trial of Neoadjuvant Therapy in Patients with Palpable and Operable Breast Cancer Evaluating the Effect of Pathologic Complete Response.

NSABP B-41 (Neo-Adj): A Randomized Phase III Trial of Neoadjuvant Therapy for Patients with Palpable and Operable HER2-Positive Breast Cancer.

ACOSOG Z1031 (Stage II-III Neo-Adj): A Randomized Phase III Trial in Postmenopausal Women w/ Clinical Stage II and III Estrogen Receptor Positive Breast Cancer.

Dune Medical Devices (DCIS): Margin Probe, a Device for Intraoperative Assessment of Margin Status in Breast Conservation Surgery.

A Phase III Clinical Trial Given Concurrently with Radiation Therapy and Radiation Therapy Alone for Women with HER2-Positive Ductal Carcinoma In Situ Resected by Lumpectomy.

NSABP B-39 (Stage 0-II): A Randomized Phase III Study of Conventional Whole Breast Irradiation (WBI) versus Partial Breast Irradiation (PBI) for Women with Stage 0, I, Or II Breast Cancer.

ECOG PACCT-1 (Adjuvant NCCCP PRIORITY TRIAL): Program for the Assessment of Clinical Cancer Tests (PACCT-1): Trial Assigning Individualized Options for Treatment.

Endurance Exercise (Stage 0-II): Effects of Endurance Exercise on Bio-behavioral Outcomes of Fatigue - A Pilot Study.

NSABP B-42 (Stage I-IIIA NCCCP PRIORITY TRIAL): A Clinical Trial to Determine the Efficacy of Five Years of Letrozole Compared to Placebo in Patients Completing Five Years of Hormonal Therapy Consisting of an Aromatase Inhibitor (AI) or Tamoxifen Followed by an AI in Prolonging Disease-Free Survival in Postmenopausal Women with Hormone Receptor Positive Breast Cancer.

NSABP B-46-I (Stage I-IIIB): A Phase III Clinical Trial Comparing the Combination of TC Plus Bevacizumab to TC Alone and to TAC for Women with Node-Positive or High-Risk Node-Negative, HER2-Negative Breast Cancer.

For more information about clinical trials for breast cancer, please contact Stacey Fischer, RN, BSN, OCN, Nurse Navigator for the Breast Program at (714)734-6233 or the Research Department at the Center for Cancer Prevention and Treatment at (714)734-6200.