Crit Care Nurs Q Vol. 39, No. 4, pp. 352-362 Copyrightc2016 Wolters...

Question Answered step-by-step Crit Care Nurs Q Vol. 39, No. 4, pp. 352-362 Copyrightc2016 Wolters… Crit Care Nurs QVol. 39, No. 4, pp. 352-362Copyright ?c 2016 Wolters Kluwer Health, Inc. All rights reserved.Nurse-Driven Catheter- Associated Urinary Tract Infection Reduction Process and ProtocolDevelopment Through an Academic-Practice PartnershipPamela Johnson, DNP, RN; Anna Gilman, BSN, RN; Alicia Lintner, MSN, CRNP-BC, CCRN;Ellen Buckner, PhD, RN, CNE, AE-CTranslating evidence-based practices to the bedside can be facilitated by an active academic- practice partnership between nursing faculty and frontline nursing staff. A collaborative effort between the university’s academic nurses and the medical center’s clinical nurses explored, cre- ated, implemented, and evaluated an evidence-based nurse-driven protocol for decreasing the rate of catheter-associated urinary tract infections. The nurse-driven protocol was piloted in 4 inten- sive care units and included nurse-driven orders for catheter discontinuation, utilization of smaller bore urinary catheters, addition of silver-based cleansing products for urinary catheter care, and education of staff on routine catheter care and maintenance. Data were collected for more than 8 months pre- and postimplementation of the nurse-driven protocol. Postimplementation data re- vealed a 28% reduction in catheter-associated urinary tract infections in the intensive care units as compared with preimplementation. Secondary benefits of this academic-practice partnership included strengthening the legitimacy of classroom content as lessons learned were integrated into courses in the nursing curriculum. The result of the partnership was a stronger sense of col- laboration and collegiality between hospital staff and the university faculty. Transformative lead- ership engaged numerous stakeholders through collaborative efforts to realize best practices. An academic-practice partnership facilitates transformative change and provides structural stability and sustainability. Key words: academic-practice partnership, catheter-associated urinary tract infections, nurse-driven protocol Author Affiliations: Adult Health Nursing Department, University of South Alabama College of Nursing, Mobile (Drs Johnson and Buckner); Staff Development, University of South Alabama Medical Center, Mobile (Ms Gilman); and Arnold Luterman Regional Burn Center, University of South Alabama Medical Center, Mobile (Ms Lintner).The authors are grateful to the University of South Alabama Medical Center for its support and partici- pation in development and successful implementation of this protocol, especially: the CAUTI prevention ac- tion team; evidence-based practice committee mem- bers, and physicians and nurses in the medical surgi- cal ICU, progressive care unit, surgical trauma ICU, and Burn ICU.352There is no actual or potential conflict of interest in- cluding financial, personal, or other relationships with organizations and companies that could inappropri- ately influence this article.The authors have disclosed that they have no signif- icant relationships with, or financial interest in, any commercial companies pertaining to this study.Correspondence: Pamela Johnson DNP, RN, Adult Health Nursing Department, University of South Al- abama College of Nursing, 5721 USA Dr North, HAHN 4068, Mobile, AL 36688 (pamjohnson@ southalabama.edu).DOI: 10.1097/CNQ.0000000000000129Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.THE Institute of Medicine report on The 1Future of Nursing highlighted the criti- cal need for nurses to be prepared to advance science that benefits patients and the capacity of health professionals to deliver safe, quality patient-centered care. An academic-practice partnership has been defined as a relation- ship between a nursing education program and a care setting, with a unified purposeNursing policies, procedures, and guidelines are expected to be founded on evidence. Translating research findings into clinical practice is a complex un- dertaking. It has been estimated that 30% to 40% of patients do not receive treatment on821 reporting, and governmental policies. Thefast pace of technological and scientific ad- vances creates an enormous mass of evidence supporting practices that improve the safety and effectiveness of patient care; however, a lag time of approximately 17 years has been noted in the implementation of best prac-3,4of improving health care delivery systems. Partnerships may vary in purpose and struc- ture. Partnerships are key in fostering care settings that are able to respond and thrive in a US health care system that is continuously growing and adapting to changes. Health care is also influenced by requirements of cre- dentialing agencies, public monitoring andthe basis of the best available evidence.There are numerous reasons for this delay in implementing best practices at the bedside, one of which is the lack of collaboration between the producers of evidence-based practice (EBP) approaches and those who implement these. The pur- pose of this academic-practice partnership description is to report on how the collab- orative relationship facilitated change in the practice setting to reduce catheter-associated urinary tract infections (CAUTIs). In addition, benefits to the academic curriculum resulted from the frontline implementation, and im- proved curricular content is an outcome ofMedicine report1 reinforced the importanceof competency in EBP as a responsibilityfor health care providers to develop andmaintain throughout their careers. Despiteacademic emphasis on the use of EBP andinstitutionally established competencies forEBP, studies have found that recent graduatesand seasoned nurses continue to report lowrates of research utilization in their clinical8,12research, and limited time and resources. Sadly, the most common sources to guide clinical practice at the bedside include per- sonal judgment based on past experiences,8tices at the bedside.the active relationship.BACKGROUND: ACADEMIC-PRACTICE PARTNERSHIPSEvidence-based practiceEvidence-based practice has been defined as a decision-making process for patient care that uses best evidence available combined with practice experience and the patient’s own values and preferences to guide patientand opinions of colleagues.Nurse-Driven CAUTI Reduction Process and Protocol 3535care. Evidence-based nursing is the processin which nurses make clinical decisions on the basis of evidence, nursing expertise, and values and/or preferences of individuals, fam-6,7The complexity of translating research findings is created by several factors including the sheer amount of information that is continually generated, the ability of the practitioner to evaluate and translate the findings into practice at the bedside. In the United States, an educational objective for baccalaureate, master’s, and doctoral education includes the ability of graduates to integrate evidence- based interventions into practice in order to provide care that is of high quality andCopyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.ilies, and communities.centered on safety.9,10,11The Institutes ofChallenges that have been cited by bedside nurses include being too busy with clinical care, having insufficient research skills or exposure to EBP, lack of interest in7,13The complexity and perceived barriers of discovering and implementing best practice elucidate the im- portance of academic involvement in guiding clinicians in developing their awareness and competencyinengaginginEBP.Anacademic- practice partnership is a relationship that supports the implementation of EBP and should continue long past a nurse’s academicpreparation.practice.354 CRITICAL CARE NURSING QUARTERLY/OCTOBER-DECEMBER 2016Collaboration and the academic-practice partnershipMany words are associated with the term collaboration. It is common to think of terms such as “cooperative work,” “shared responsi- bility,” “making decisions” and “solving prob- lems” as being associated with collabora- tion. Traditionally, collaboration in the hospi- tal setting is thought of as an ongoing, inter- disciplinary process in which nurses, physi- cians, and other professionals work together to maximize delivery of care to the patients they serve. Collaboration is a process and an outcome where individuals work together1416Six character- istics of collaboration identified by Springer et al7 include (1) voluntary participation, (2) mutual valuing, (3) mutual goals, (4) shared responsibility, (5) shared resources, and (6) shared accountability. Frontline nurses at the University of South Alabama Medical Center (USAMC) are currently engaged with faculty from the University of South Alabama Col- lege of Nursing (USACON) in an academic- practice partnership in a collaborative effort to focus on enhancing the quality of pa- tient care through the implementation of EBP. In the academic-practice partnership, both groups contribute their perspectives to better understand how to approach a specific area in health care delivery that requires a perfor- mance improvement initiative. Each party has a mutual respect for each other’s knowledge, expertise, and skills and values their mutualto solve complex problems.interdependency.7,15Background of the partnershipThe USAMC is an acute care hospital lo- cated in Mobile, Alabama, serving as the area’s only level 1 trauma center and regional burn center. It also provides care for the ma- jority of the indigent population in the city, who often use the medical center as their pri- mary care resource. During the time of this study, the USAMC was recognized as caring for a high-acuity population. The USA Medi- cal Center is ranked 44th of 3200 hospitals nationwide in “acuity index” measuring thenursing.To ensure that provision of patient careis based on evidence, the facility established an EBP committee in July 2010. The EBP committee is a nursing led, multidisciplinary committee that uses evidence-based research to positively impact changes in patient care, safety, and satisfaction. The EBP committee partnered with the USACON faculty and the Biomedical Library. Members of this commit- tee include multiple disciplines as appropri- ate for the clinical topic being explored. The EBP committee meets on a monthly basis toCopyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.As a result of these characteristics, the patients served by the medical center have high-complexity illnesses. The USAMC serves as a multidisci-plinary teaching and research facility.Formal relationships are established at the senior leadership level and practiced at mul- tiple levels throughout the organization. The USAMC and the USACON have had a long- standing relationship based primarily on clin- ical placement for students and faculty ap- pointment to hospital committees includ- ing the EBP Committee and Nurse Practice Congress. The USAMC and the USACON share related visions, missions, goals, and values that center on providing the highest level of care to our patients and educating the nextgeneration of health care providers.Evidence-based improvement processesIn the last 8 years, academic nurses andfrontline nurses at the USAMC and the US-ACON have participated in national studiesas part of Transforming Care at the Bed-side and the Improvement Science Research17,18severity of patients’ illnesses.These experiences have fur- ther developed the ability of frontline staff to lead change initiatives. Nursing staff have im- plemented “tests of change” and contributed to quality improvement processes leading to many successful initiatives. Faculty have collaborated through major studies and en- gaged students at undergraduate and gradu- ate levels in conducting unit-based studies. These collaborations further developed the relationships between practice and academicNetwork.promote meaningful engagement in ongoing improvement projects.The academic-practice partnership has opened many doors for collaboration. The following exemplar was a multiyear process that resulted in quality improvements in practice and educational improvements in the academic setting. Research skills capac- ity grew across the partnering organizations with stronger bridges between the producers of research evidence and that evidence being applied to practice.EVIDENCE-BASED PRACTICE PARTNERSHIP EXEMPLAR: DEVELOPMENT OF THE NURSE-DRIVEN CAUTI REDUCTION PROTOCOLPurposeThe purpose of this exemplar is to demon- strate the collaborative relationship between the University’s academic nurses and the frontline nurses in exploring, creating, imple- menting, and evaluating an evidence-based nurse-driven protocol for decreasing the rate of CAUTIs. Furthermore, the exemplar listed later describes how the EBP process resulted in a positive impact on patient care. In working together toward a common goal of implementing evidence-based interventions to decrease rates of CAUTIs, both institutions contributed to developing a collaborative pro- cess more effective than either could alone.Steps in EBP and improvement methodologyThe former USAMC performance improve- ment methodology, “ICARE,” was utilized to organize and complete the project. Mem- bers of the EBP committee undertook a pro- cess improvement approach to reduce CAUTI rates in the hospital, especially in the in- tensive care units (ICUs). The I stands for “Identify,” an opportunity for improvement. In this stage, the idea for improvement was identified, and the CAUTI Action Team was formed. The next step “Clarify” involved eval- uating the current process and practice forindwelling urinary catheter insertion, main- tenance, and discontinuation. Several factors involving insertion, maintenance, and dis- continuation of indwelling catheters were identified. During the “Analysis” step of the process, drilled down de-identified data col- lected from charts of ICU patients who devel- oped CAUTIs over a specific period of time were collected and evaluated and contribut- ing factors were considered. Evidence-based practices for CAUTI reduction from the liter- ature and other sources were evaluated and compared with current practices. “Revision” of the action plan was the next step. Dur- ing this phase, the nurse-driven protocol was developed and the pilot was implemented. The final steps are “Evaluate/Educate.” This is where the pilot project for CAUTI reduction in the ICUs was evaluated. It was during this phase when exciting results were realized, as outlined in more detail in the following paragraphs.Partnership for improvementThe CAUTI reduction project began when infection control staff reported baseline data regarding CAUTIs to the EBP committee. Data included infection rates per 1000 catheter days, number of CAUTIs, and number of catheter days. After a review of the CAUTI rates at the medical center in comparison to national averages, the EBP committee iden- tified a need for improvement in this area. To focus on the revision of current practice at USAMC, a subcommittee of the EBP com- mittee, the CAUTI Action Team, was formed. This multidisciplinary team consisted of USAMC staff particularly intensive care sup- port (ICU nurses, nurse practitioner, nurse manager, trauma surgeon, and nurse educa- tors), CON faculty, and infection control. The CAUTI Action Team was tasked to investi- gate current policies, procedures, and prac- tices regarding care of patients who require an indwelling urinary catheter and to pro- pose changes that would lead to the ultimate goal of reducing CAUTIs at the USAMC. For this pilot project, the ICUs were primarily the area of focus due to higher CAUTI ratesNurse-Driven CAUTI Reduction Process and Protocol 355Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.356 CRITICAL CARE NURSING QUARTERLY/OCTOBER-DECEMBER 2016and catheter utilization. Institutional review board approval was obtained.Baseline dataThe initial step in this CAUTI focus included assessment of current CAUTI reduction mea- sures and unit surveillance. A CON faculty member conducted a site visit and through direct observation of intensive care patients who had urinary catheters in place identified areas for improvement in routine daily main- tenance and infection control measures.To determine whether there were specific clinical factors that contributed to the de- velopment of CAUTIs in the ICUs, baseline surveillance data were collected in 1 partic- ular unit. The initial data were reviewed and a “drill down” was done on every CAUTI for 12 months. Clinical factors that were evalu- ated included obesity, incontinence, specific infection, number of catheter days, temper- ature, blood glucose control, urine output, ventilator status and settings, indications for catheter, and documentation of compliance with current CAUTI reduction measures dur- ing patient transport (emptying the drainage bag before transport and maintaining the catheter below the level of the bladder). In addition, a retrospective review of base- line data (number of CAUTIs and number of catheter days) across multiple units revealed that the CAUTI rate for the combined units was 0.60% (25 CAUTIs per 4154 catheter days).CAUTI Action Team processesThrough a series of focused meetings, the CAUTI Action Team reviewed current litera- ture related to best practices for indwelling urinary catheter insertion, maintenance, and CAUTI reduction, as well as evaluation of sev- eral shared protocols solicited from similar level 1 trauma centers in the region. The team determined that delays in discontinuation of catheters (increased number of catheter days) were occurring because nurses were required to obtain a physician’s order for removal of an indwelling urinary catheter. The team’s physi- cian champion explained that nurses insertindwelling urinary catheters and unless there was a specific issue, physicians are more prone not to consider removing a catheter be- cause the physician’s interaction with it was limited. Increased number of catheter days is known to be a major contributor to higher19Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.With this in mind, the team de- veloped an order set that included the nurse- driven protocol (see Figure 1). The order set included an option for nurse-driven protocol in the majority of cases unless specific exemp- tions were met (an opt out process). Changes in policies and procedures included utiliza- tion of smaller bore urinary catheters, addi- tion of silver-based cleansing products for uri- nary catheter care, and education of staff on routine catheter care and maintenance. The newly developed order set with the nurse- driven protocol and revised policies and pro- cedures were reviewed and approved by the appropriate hospital committees and adminis- trators for use in a pilot study to be conductedCAUTI rates.in the units at the USAMC.The main focus of the nurse-driven proto-col was timely removal of indwelling urinary catheters when clinically indicated, without requiring an additional physician’s order. The order set allows the physician to decide whether the patient will be included or ex- cluded in the nurse-driven protocol. If the physician places the patient on the proto- col, once the patient no longer meets the cri- teria for an indwelling urinary catheter, the nurse may remove the catheter. If the physi- cian excludes the patient from the protocol, a reason from the exemption criteria (listed on the order set) must be documented. For patients excluded from the protocol, a sep- arate physician’s order is required to discon- tinue the catheter. The need for the catheter is assessed daily during multidisciplinary ICU daily rounds, where it is determined whether the patient meets criteria for an indwelling urinary catheter and documents the indica- tion for the catheter (see Figure 2).Initiation of new protocol roll outThe next step involved education of all nursing staff in the involved units, the chiefNurse-Driven CAUTI Reduction Process and Protocol 357Figure 1. Nurse-driven protocol order set.Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.358 CRITICAL CARE NURSING QUARTERLY/OCTOBER-DECEMBER 2016Figure 2. Multidisciplinary intensive care unit daily rounds and goals.Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.residents, and surgery/medicine physician teams. The education included current CAUTI statistics for the USAMC and the spe- cific units, an introduction of the nurse driven protocol and the evidence that guided its de- velopment, and a review of routine catheter care and maintenance. A laminated copy of the order set was posted in each unit. The re- vised orders, policies, and procedures were implemented with an 8-month surveillance pilot to evaluate effectiveness. Indwelling uri- nary catheters per unit, as well as the num- ber of patients who were placed on the nurse driven protocol were tracked. Infection con- trol continued to monitor and report data in- cluding number of CAUTIs and number of catheter days for combined units.RESULTSThe institutional review board at the Uni- versity of South Alabama approved the study as a secondary analysis of de-identified clin- ical data. Data from the units were collected from all units and reviewed. Unit-specific data included number of CAUTIs per month and catheter days per month. Data were available from nightly unit reports and additional data collected by unit managers/educators.Data covering 8 months pre- and postim- plementation of the nurse-driven protocol re- vealed a 28% reduction in CAUTIs for the combined ICUs. The improvements were re- flected in postimplementation lower rates of CAUTIs (actual, 36% reduction), lower num- ber of catheter days (actual, 11% reduction), and lower CAUTI rates (0.43% at postimple- mentation compared with 0.60% at preimple- mentation).De-identified data regarding CAUTIs in spe- cific ICUs both pre- and postimplementation, including number of catheter days, if patient was on the nurse-driven protocol or not, and average day to CAUTI revealed a reduction in actual number patients with catheters, num- ber of CAUTIs, and number of catheter days from pre- to postimplementation. Two pa- tients repeated with a second CAUTI and 2 other patients postimplementation met crite-ria for exemption. The average day to CAUTI increased from 8.9 to 16.5. This was proba- bly a reflection of 2 factors. One is that with longer days, there is an increase in CAUTI risk and actual number of CAUTIs, and with the nurse-driven protocol, more catheters were being discontinued earlier, resulting in fewer CAUTIs. When CAUTIs did develop, they oc- curred at a later date, resulting in a later aver- age day to CAUTI.Closing the loopBased on the effectiveness of the proto- col, change occurred in the practice set- ting. The order set is still in use with continued trends in CAUTI reduction. One step remained and that was bringing the evidence-based protocol to the academic set- ting. Faculty who served on the CAUTI Ac- tion Team collaborated with the course fac- ulty for the undergraduate-level clinical nurs- ing skills course to include information about the evidence-based CAUTI reduction protocol at the USAMC in the course. For the skills course, the order set for the nurse-driven pro- tocol for catheter removal was included in the simulated patient charts used for skills check- offs. The process of the nurse-driven protocol was also embedded into the skills checkoff sheet that is used by students as they learn how to insert, maintain, and discontinue an indwelling urinary catheter, and it is used by faculty to evaluate student mastery of this skill.DISCUSSIONThis academic-practice partnership has proven beneficial to both systems as needs of patients, nurses, facility, faculty, and students are being met. Academics often find them- selves isolated in some ways, teaching what is considered to be best practices and pro- cesses, but often lack follow through in mak- ing sure that our graduates enter a practice environment where best practices and pro- cesses are part of the culture. As participants in the EBP committee, academics are able to evaluate frontline nurses’ knowledge of bestNurse-Driven CAUTI Reduction Process and Protocol 359Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.360 CRITICAL CARE NURSING QUARTERLY/OCTOBER-DECEMBER 2016practices, resources to improve practice, and processes to improve practice at the bedside. The academic membership of the EBP com- mittee serves to enhance committee mem- bers’ and frontline nurses’ research skills, aid in evaluating current policies and processes, and act as mentors for nurses as they evaluate current practices and lead change to advance the quality of care.Another benefit that faculty have realized through this partnership is keeping touch with the complexities of providing patient care in a highly acute hospital setting. A secondary strength of this academic-practice partnership lies in the ability of nursing students, from undergraduate to graduate levels, to apply classroom knowledge and de- velop skills as they actively participate in the EBP process through research assignments and capstone project completion in their scholarly endeavors. The partnership has expanded to include academic and clinical partners collaborating in professional roles as they jointly disseminate successes through scholarly works including publications and presentations at local, state, regional, and national venues.Faculty are also able to bring examples of actual EBP initiatives to the classroom, thus strengthening the link to real clinical practice and the legitimacy of classroom content.Lessons learned from this collaborative partnership are integrated across the cur- riculum at the USACON. For example, in a senior-level EBP course, students evaluate policies and protocols from the USAMC and offer input for updates/improvement based on EBP. Students share their experiences in utilizing the EBP process to critique current policies through presentations to the EBP committee and hospital staff. This also en- ables the students to gain experience in pre- senting their findings to an audience and starts them out with something worthy of including in their CV as they pursue em- ployment. Information about evidence-based practices is incorporated into a first semester skills class. The lesson in which students learn to insert and maintain indwelling uri-nary catheters contains a focus on preventing CAUTI.Through this collaborative academic- practice partnership, a stronger sense of collegiality between hospital staff and uni- versity academics has developed, knowledge and skills have been strengthened, and care based on the best current evidence has been implemented.Practice empowermentMeasuring the number of indwelling uri- nary catheters per month served as positive feedback to the nurses. When the health care team saw the results of lower catheter days, lower CAUTI rates, they realized that their care made a difference and were inspired to continue providing care that was based on the best evidence in order to achieve the best outcomes for their patients.Practice partners feel empowered as they realize that they have support of academics and are able to improve their skills in im- plementing changes to patient care that are based on EBP. The partnership has ignited the passion and vision it takes to achieve lofty goals of improving patient care and out- comes. This academic-practice partnership acts as a way to close the loop in improving patient care in a timely manner. The benefits of the partnership are reciprocal.From the academic standpoint, participants in the EBP committee were able to evaluate staff member’s knowledge of best practices, resources, and processes to improve practice. Academics were able to increase staff mem- bers’ skills, knowledge, and attitudes in their ability to formulate, implement, and evaluate practice changes. We “talk the talk” in the classroom; this partnership allows us to “walk the walk” in supporting EBP implementation in practice.Evidence-informed educationThere are no limits in education in the nurs- ing profession. The emphasis on education is not only in the classroom but also in all as- pects of health care. Nurses are teachers. The main goal of nursing educators and frontlineCopyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.nurses is to provide the best care to patients. Evidence-informed education makes each as- pect of nursing more caring than ever before, because our care is based on the best evi- dence leading to better outcomes and health- ier patients.Interprofessional perspectivesThe team’s physician champion, a seasoned trauma surgeon, board certified in critical care, agreed that a nurse-led initiative to re- move catheters was the best option. He noted that nurses insert the catheters and unless there was a specific issue, physicians do not place or handle the catheter. He explained that he was more prone not to consider re- moving an indwelling urinary catheter be- cause other than ordering it, the physician interaction with the device was limited, un- like a central line that he placed and main- tained when issues arose. Following the suc- cessful implementation in reducing CAUTIs, he noted that the nurse-driven protocol re- moved this unnecessary delay in indwelling urinary catheter discontinuation. He went on to advocate that the protocol incorporates the bedside nurse into our multidisciplinary method of ICU patient care.The multidisciplinary collaboration of the team produced efficient and detailed plansREFERENCES1. Institute of Medicine. The Future of Nursing: Lead- ing Change, Advancing Health. Washington, DC: The National Academies Press; 2011. doi:10.17226/ 12956.2. American Association of Colleges of Nursing. Academic-practice partnerships. http://www.aacn. nche.edu/leading-initiatives/academic-practice- partnerships/GuidingPrinciples.pdf. Published 2012. Accessed February 25, 2016.3.Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: understand- ing time lags in translational research. J R Soc Med. 2011;104(12):510-520. doi:10.1258/jrsm.2011 .110180.4. Thompson DS, Estabrooks CA, Scott-Findlay S, Moore K, Wallin L. Interventions aimed at increasing re-for achieving each step of project implemen- tation. Health information technology was engaged to prepare the new order set for electronic implementation. Each individual’s perspective and expertise fueled engage- ment, innovation, and an overall strong, thoughtful protocol. Creating improvement strategies together is a win for everyone with the patient in the center.Ongoing collaboration for improvementThe plan do study act model (PDSA model) of EBP has since been adopted as the model that guides improvement at the USAMC. Pro- cesses are in place to ensure that new mem- bers of the EBP committee are provided with an orientation to EBP. Students (hon- ors undergraduate, and doctoral level) are involved in improvement projects so that they can model the collaborative partner- ships, as well as investigate specific top- ics. The Nursing Practice Congress actively identifies issues from the frontline that af- fect care and create teams to address them. The concept of collaborative practice in an academic-practice partnership is stronger through the formalizing of the process and integration across settings and personnel. The structure supports processes of active collaboration.search use in nursing: a systematic review. Imple-ment Sci. 2007;2:15. doi:10.1186/1748-5908-2-15.5. Melnyk B, Fineout-Overholt E, Kraus R, et al. Nurses’ perceived knowledge, beliefs, skills, and needs re- garding evidence-based practice: implications for accelerating the paradigm shift. Worldviews EvidBased Nurs. 2004;1(3):185-193.6. Sigma Theta Tau International. Evidence-basednursing position statement. http://www.nursing society.org/why-stti/about-stti/position-statements- and-resource-papers/evidence-based-nursing- position-statement. Revised 2005. Accessed April 8, 2016.7. Springer P, Corbett C, Davis N. Enhancing evidence- based practice through collaboration. J Nurs Adm. 2006;36(11):534-537.Nurse-D