News and views fall 2013
News & Views is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center.
news views Fall 2013 A Publication of the Department of Nursing and Patient Care Services University of Maryland Medical Center The Magnet Re-designation Submission Kristin L. Seidl, PhD, RN, Director of Quality and Safety and Rachel Hercenberg, MS, Project Specialist, Clinical Practice & Professional Development The University of Maryland Medical Center (UMMC) has been a Magnet designated organization since 2009. In order to maintain Magnet status, UMMC must submit written documents every four years showcasing how nursing at UMMC meets the program’s standards. On August 1, 2013, the UMMC Magnet re-designation document was submitted to four appraisers and to the American Nurses Credentialing Center (ANCC). The ANCC has oversight of the Magnet Recognition Program and is the largest and most prestigious nurse credentialing organization in the United States. Unlike the 15-inch thick, printed document that was mailed across the country in 2009, this year’s document was sent as a 15 GB thumb drive. Over the past two years, the Magnet Team identified appropriate evidence and collected information to be submitted in the written documents. With help from nurses and staff members across the Medical Center, Kristin Seidl, PhD, RN, Director of Quality and Safety, compiled the content. In the three months prior to submission, Dr. Seidl met with Rachel Hercenberg, MS, Project Specialist, CPPD twice per day with many phone calls in between to strategically retrieve and review demonstration documents. With collaboration from the entire Department of Clinical Practice & Professional Development, the team secured and formatted demonstration documents to support the 622 pages of text. Using Adobe Acrobat Professional, Hercenberg created a document that resembled an electronic encyclopedia: 622 single-spaced PDF pages, with 1,886 demonstration PDF documents, hyperlinked throughout those 622 pages. This was no easy feat! Consider for a moment the organizational skill that is needed to keep track of over 1,800 documents (some electronic, some hard copy) and the attention to detail required to ensure that each document was inserted in the appropriate place in the document. As one can imagine, it turned into a very simple strategy for developing carpal tunnel continued on page 10. syndrome and a newfound need for eye glasses! 2009 2013 Lisa Rowen’s Rounds: Writing the Chapter with the Patient I recently read a blog posted by Eric Palmer, RN, BSN, MSN, MHA that conceptualizes a patient’s experience as a chapter in their life. As an avid reader, I related to this notion, and thought about how often people describe a meaningful event as a chapter in their personal book. Frequently, many people want to end a particular chapter that was Lisa Rowen, DNSc, RN, FAAN, painful to live through and move on to better times. Senior Vice President of When our patients and family members are in the Patient Care Services and Chief Nursing Officer thick of it, they are looking for the metaphorical light at the end of the tunnel, the sun peeking out of the clouds or a new chapter to begin. Consider your life story and all the chapters in your book. You may have many chapters on your childhood, your education, career and your significant relationships. If you are a parent or grandparent, each one of your children and grandchildren may have their own chapter in your book. Who are the significant characters in your book? How would you describe them and their impact on you? How do they speak to and with you? continued on page 4. 2 Fall 2013 In This Issue 1 1 2 3 6 6 7 9 12 14 15 16 17 18 19 Magnet Re-Designation Lisa Rowen’s Rounds Corporate Compliance Blue Button Achievements Team Transport Journal Club Respiratory Ventilator 5K Magnet Site Visit Prep Education Achieving Meaningful Use I Was Noticed Dietetic Internship Healing Arts Exhibit Spotlight on Pharmacy Certification Corner Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer Toya Jackson, Director of Compliance In each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) for News & Views. We are looking for new ways to reach out to employees to raise awareness of compliance issues. Please let us know what you think, or suggest topics by emailing firstname.lastname@example.org or email@example.com. Compliance News Recent changes this year in the final Omnibus Rule under the Health Insurance Portability and Accountability Act (HIPAA) have heightened the requirements to notify patients in the case of a “breach” of their protected health information (PHI). Unless Corporate Compliance determines otherwise, we are now obligated to report ANY breach to affected patients. To protect our patients, this is a reminder to continue the practice of only accessing patient’s PHI for the purpose of Treatment, Payment, and Health Care Operations (TPO). 20 ARC Framework 22 The Angel Award 24 Clinical Practice Update Find News&Views online at http://www.umm.edu/nursing/newsletter.htm and on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm Editor Carolyn Guinn, MSN, RN Magnet Director, Clinical Practice & Professional Development Associate Editor NEWS & VIEWS is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center. Scope of Publication The scope of NEWS & VIEWS is to provide clinical and Displaying Credentials Rachel Hercenberg, MS Project Specialist, Clinical Practice & Professional Development Editorial Board professional nursing and patient care services practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines The UMMC Standard for displaying of credentials is based on the ANCC Guidelines. The preferred order is: • highest earned degree (can list more than one if in different fields) • licensure • state designations or requirements • national certifications and honors • other recognitions Nurses with two or more nursing degrees (MSN, BSN) should only list their highest nursing degree, along with other degrees obtained. Example: Betty Smith, MSN, MBA, RN. Why this order: The education degree comes first because it is a “permanent” credential, meaning it cannot be taken away except under extreme circumstances. The next two credentials (licensure and state designations/requirements) are required for you to practice. National certification is sometimes voluntary. Awards, honors, and other recognitions are always voluntary. If you would like additional information, please visit http://www.nursecredentialing.com and search using the word “credentials.” Allison Murter, MSN, RN Clinical Practice & Education Specialist, Clinical Practice & Professional Development Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice, Professional Development, Neuroscience, Behavioral Health and Supplemental Staffing Suzanne Leiter Executive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer Chris Lindsley Director, Communication Services University of Maryland Medical System/Center Anne Haddad Publications Editor University of Maryland Medical System Lisa Rowen, DNSc, RN, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer Send completed articles via e-mail to firstname.lastname@example.org. Please follow the guidelines provided below. 1. Font – Times New Roman – 12 pt. black only. 2. Length – Maximum three double spaced typed pages. 3. Include name, position title, credentials, and practice area for all writers and anyone named in the article. 4. Authors must proofread the article for spelling, grammar, and punctuation before submitting. 5. Provide photos and embedded images in separate .jpg files. 6. Submit trend data in graphic format with labeled axes. 7. References must be numbered consecutively and provided at the end of the article. 8. Editor will seek expert review of articles to verify and validate content. 9. Articles will be accepted based on appropriateness of content and availability of space in each issue. 10. Articles that do not meet the above guidelines will be returned to the author(s) for revision and resubmission. ISSUE Winter 2014 Spring 2014 Summer 2014 Fall 2014 DUE DATE January 6, 2014 May 12, 2014 July 8, 2014 October 6, 2014 news & views CLINICAL INFORMATICS 3 Blue Button Robby Klawitter, MS, ACNP, CCRN, Senior Nurse Practitioner, Clinical Informatics – The EPIC Project Viewing and downloading your personal health data may have just become as simple as clicking a button. Blue Button is a federal initiative intended to provide Americans with convenient and secure online access to their health records. Originally introduced in October 2010 by the Veterans Administration (VA), the Center for Medicare and Medicaid (CMS), and the Department of Defense (DoD), Blue Button allows individuals who choose to participate access to their own medical information through a secure Internet site. Users may choose to share crucial health information among different providers or with other trusted caregivers. Utilizing this cost-free option, patients have the ability to monitor their medical information while ensuring that it is not only accurate but current. Blue Button serves as an electronic repository for personal health information, including prescription drug history, allergies, lab test results and treatment information. There are times when access to this application could make the difference between life and death. If a person becomes ill or is injured and is unable to communicate for themselves, their records could be viewed by their designee to communicate allergies and prescription drug history to avoid potentially lethal consequences. If someone is traveling and becomes mobile version of this tool, iBlueButton. Much like its predecessor, iBlueButton affords patients the ability to access and share medical information with their health care providers from any location and at any time but with the added convenience of mobile device utilization. Some potential consumers have expressed safety, security and privacy concerns with retrieving and transmitting personal health data through Blue Button. It is important to note that the Health Insurance Portability and Accountability Act (HIPAA) mandates that health care institutions and providers have safeguards in place to protect personal health data. Access is strictly limited to the consumer of this service and his designees. Set in place by the Centers for Medicare and Medicaid Services (CMS), the Meaningful Use (MU) program is comprised of guidelines which direct use of electronic medical records (EMRs) by healthcare providers. In order for hospitals to meet the MU Stage 2 program requirements, a certain percentage of patients must be able to electronically access their medical records through tools like Blue Button. The exact manner in which Blue Button and similar applications will be implemented at the University of Maryland Medical Center to meet the MU requirements has yet to be determined; however, this should not preclude members of the health care team from becoming familiar with this new and exciting option for securely accessing and exchanging health information. References iBlueButton 4.0.(no date) . Retrieved September 30, 2013, from http:www.humtrix.com/ ibb.html Chopra, A. (2010,). Blue Button Provides Access to Downloadable Personal Health Data. Office of Science and Technology Policy. Retrieved September 28, 2013, from www. whitehouse.gov Download Claims with Medicare’s Blue Button (no date). Download Claims with Medicare’s Blue Button. Retrieved October 7, 2013 from, www.medicare.gov/manageyour-health/blue-button/medicare-blue-button.html Meaningful Use (no date). Policy Making, Regulation, & Strategy. Retrieved October 21, 2013, from http://www.healthit.gov/policy-researchers-implementers/meaningful-use Miliard, M. (2013). Health Tech Hatch to Expand Blue Button. Retrieved October 4, 2013, from http://www.healthcareitnews.com/news/health-tech-hatch-expand-blue-button Ricciardi, L (2013). The Blue Button Movement: Kicking off National Health IT Week with Consumer Engagement. Health IT Buzz. Retrieved October 1, 2013, from http:www. healthit.gov/buzz-blog.electronic-health-and-medical-records/blue-button-kickingnational-health-week-consumer-engagement ill, they can access their own health history, lab values and drug history to communicate to a new provider. Health information tools and applications such as Blue Button can be configured to alert individuals of approaching appointments, provide valuable information to complete insurance claims, and may be customized to deliver wellness reminders to help users reach health-related goals. Through use of the Medicare Blue Button, beneficiaries can view and download information which encompasses three consecutive years of their most recent health history. Medicare participants will be better able to navigate their benefits, as they are able to access claims information on services rendered under parts A and B as well as a comprehensive list of medications acquired under Part D. Veterans can use the Blue Button feature located on the MyHealthVet website to download clinical notes, emergency contacts, demographic information, and lists of their prescription medications. Utilizing Blue Button, veterans can also sanction transmission of medical data from one treating health care provider to another. It has been estimated that nearly half of the American population uses smart phones or other mobile devices, making access to information easier than ever. Recently, Humetrix introduced the 4 Fall 2013 Rounding Report, continued from page 1. Communication is key in our personal stories. If we reflect on the many ways thoughts and feelings can be communicated, they can be surprisingly different. Following is a diagram that helps children understand the many ways to say the word “said”. If we were a patient whose pain was not well-controlled, the chapter could read: “Please help me, I’m in pain,” sobbed the patient. Sadness “Please help me, I’m in pain,” screamed the patient. Pain “Please help me, I’m in pain,” mumbled the patient. Tiredness “Please help me, I’m in pain,” fumed the patient. “Please help me, I’m in pain,” pleaded the patient. Anger Wanting “Please help me, I’m in pain,” stammered the patient. Fear Each one of the above statements implies a different patient experience, doesn’t it? From the shoes of the patient, depending on the verb selected, the reader of the chapter interprets a completely different situation and the chapter takes on a new meaning — for the reader, and more importantly, for the patient. In our recent C2X Employee Communication Forums, we spoke a lot about empathy. When we feel empathy for another person, we are able to identify with and understand their situation or feelings. From a point of empathy, we can positively contribute to and co-write, along with the patient, their chapter entitled “My experience as a patient at UMMC.” The setting is the Medical Center and the characters are the patient, family members and every one of us, the people who care for or support the care of the patient. How we contribute to shape the chapter of every patient’s life is up to us. Read on to see how Eric Palmer, Patient Experience Director at Saint Francis Hospital-Bartlett in Bartlett, Tennessee conceptualizes it, from the perspective of the patient. continued on page 5. Patient and Family Partnership Council: left to right - Diana MacFarlane, BS, MLS III HEW, Laboratory Integration Team; Mary Pat Yater, Family member; Melissa Parker, Patient and employee; Marjorie Fass, Patient; Jerry Chiat, Patient; Eileen Chiat, Family member; Kerry Sobol, MBA, RN, Director, Patient Experience, Commitment to Excellence, Volunteer Services, Patient Transportation Services; not pictured, Michael Yater, Patient (he took the picture). news & views Rounding Report, continued from page 4. 5 Hello, I am your patient... We are creating a chapter in my life. You control a large part of this part of my life’s story. For the time being you and I are co-authors of me and of my experience as a patient in your care. Let’s get started. Any story has the following elements. 1. Setting: You control most of the setting in this story. By Eric Palmer, RN, BSN, MSN, MHA, Patient Experience Director at Saint Francis Hospital-Bartlett in Bartlett, Tennessee. Reprinted with permission of the author. • Please listen to me. I may not be a nurse or a doctor, but I know how I normally feel. I don’t feel normal, so I came to you. Help me, but please listen to me first. 2. Characters: Obviously you and I have a starring role in this story, but there are many others. • Some I will never meet face to face, but they can control my destiny in this story, just as much as you. • I want to believe that the only villain in the story is what is making me sick. I need heroes. I need the kind of hero that takes the time to listen, to ask and to respond quickly and kindly. 3. Conflict: I most certainly have conflict; otherwise, I would not be here. Ironically, as your co-author, I might not fully understand the conflict raging inside me. Norman Cousins wrote a book about the conflict experienced in his own story called Anatomy of an Illness. It is remarkable how many things on his list are the same conflicts I am experiencing. My conflicts might be that I feel... • • • • • • • …helpless. …I may never function normally again. …as though I am a burden to you and to my loved ones. …conflicted between wanting to be alone, but yet, being left alone. …a lack of self-esteem, since maybe my illness was caused by me, because I am inadequate. …resentment. …confused. The technology surrounds me, yet, I may go days (certainly hours) without knowing the results of the last exam or worse the definitive answer is, “The test results are inconclusive.” 4. Climax: The highest point of tension in any story often involves a decision that needs to be made. I may fear those decisions because they… • …are made about me but without me knowing. • …may rest solely on me and I don’t think I know enough to make that decision. 5. Resolution: Even the end of this little story is written by both of us. It is not just me and not just you. But, I’m the one who has to write the other chapters of my life’s book. You can help me resolve this part of my story and continue on to other ones in my life if you will: • Please answer my questions. If you do not know, that is okay. Just tell me you don’t know, but please get me the information that will help answer my questions. • Please tell me about my medications. All of them. Even if I take them at home regularly, I may not be taking them the right way. But, always tell me about the new medications. • Please finish this part of our story in a language and at the level I can understand. Please ask me to teach you the information you shared with me. Rather than merely repeating back to you the same words you used. You see, I need to be as independent as possible when I leave your care. So, here we are at the conclusion of our story together. I know it wasn’t always easy. I know you were co-authoring many other stories at the same time as we co-authored mine. But, I never felt that there were any other authors out there. Thank you for your time, your care and for being a hero...my hero and my family’s hero. 6 Fall 2013 Achievements Congratulations to the following UMMC Respiratory Therapists and Physical Therapists on promotions and degree completions from July to September 2013 ! RESPIRATORY CARE Promotions Paul Johnson, RRT Promoted to Clinical Supervisor Academic Achievement Dino Gaetani, BS, RRT Earned BS in Health Services Administration Colorado State University DEPT. OF REHABILIATION SERVICES Promotions Sarah Tuck, PT, DPT Promoted to Senior Therapist Kristin Eyler, DPT Promoted to Senior Therapist Academic Achievement Renuka Roche, PhD, OTR/L Earned PhD, UMB School of Medicine, Department of Physical Therapy and Rehabilitation Science Team Transport: Celebrating Our Connection to Patient Care By Sean J. Barrett, BS, Manager, Inpatient Transportation In 2013, November 3-9 was National Patient Transport Week. As transporters, we take great pride in the contributions the transport team makes to ensure our patients receive the excellent care they expect while at the University of Maryland Medical Center (UMMC). The Inpatient Transportation Department (IPT) supports the Medical Center clinical staff by assisting them with the safe and efficient patient transport from the bedside to treatment areas. The department also provides assistance upon discharge and transport of the deceased. Inpatient Transportation provides services to noncritical care inpatients throughout the UMMC campus and supports the direct care cliniciansâ€™ ability to remain in their respective units/ departments. IPT serves everyone from infants to geriatric patients that do not require cardiac monitoring or other specialized medical equipment. Inpatient Transportation is a small but very efficient team of 20 staff members. During FY 13, transporters performed 58,977 trips, with an average completion time of 20 minutes. Individually, each transporter exceeded 2,600 transports in FY 13. Many team members are able to provide safe escort to patients in hospital beds with attachments such as IV poles. They are very aware of patient and employee safety goals, including safe moving and lifting and hand hygiene compliance. Even with the high volume of FY 13 transports, there were no reported incidents of serious injury to transporters while performing their daily tasks. Each transporter consciously supports patient care outcomes by monitoring hand hygiene performance. The team was successful in achieving 100% hand hygiene compliance on several audits throughout FY 13. Inpatient Transportation aspires to achieve hand hygiene scores of 95% or greater throughout FY 14. A Managerâ€™s Perspective I have worked at UMMC for 20 years, with the majority of those years spent in the Guest Services department. My knowledge of hospital operations outside of my department was based on what I could quickly glean from escorting a patient or a family member to a nursing unit or a treatment area. In September 2011, I became the manager of IPT. In this role, I have gained more exposure to patient care operations beyond the revolving door and realized the impact my department has in assisting nurses to provide world-class patient care. When I first came on board with IPT, I quickly realized our nurses have a tremendous responsibility in providing the excellent care our patients deserve. As I rounded on the units, I was amazed with how UMMC nurses perform their duties with professional integrity and a caring nature, especially while being responsible for so many patients. I immediately became dedicated to ensuring that nurses would not feel burdened by transporting unmonitored patients throughout the Medical Center. I want nurses to have confidence in their partnership with IPT, and feel comfortable relying on IPT services when needed. Inpatient Transportation staff look forward to providing excellent customer service that will continue to strengthen the relationships with our Patient Care Services colleagues. The department recently enjoyed the opportunity to participate in the Clinical Practice Summit and enjoyed a warm reception from our nurse partners. Inpatient Transportation staff looks forward to participating in other activities sponsored by Lisa Rowen, DNSc, RN, FAAN, Senior Vice President of Patient Care Services and Chief Nursing Officer and our fantastic group of nurse leaders. It has truly been a pleasure for the IPT staff to share in the success that UMMC has achieved through the hard work and dedication of the Medical Center nurses. news & views Journal Club 7 Perceptions of Pain Management Therapy and Patient Satisfaction Levels Mercy Ejikemeh, MPH, PMC, BSN, RN, CMSRN, SCN II; Lynnee Roane, MS, RN, Nurse Researcher, CPPD and Karen Kaiser, PhD, RN-BC, AOCN, CPC, Quality & Safety September is National Pain Awareness Month. This, in conjunction with the Magnet and HCAHPS focus on satisfaction with pain management, guided the article selection for this month’s Journal Club. “Pain management is a challenging issue and one in which I was excited to learn more about with the hopes of advancing my pain management skills to ultimately improve patient outcomes.” Mercy Ejikemeh, MPH, PMC, BSN, RN, CMSRN, SCNII Surgical Intensive Care Unit In September, Ejikemeh hosted the September Journal Club meeting to review the article “Patient Perceptions of Pain Management Therapy: A Comparison of Real-Time Assessment of Patient Education and Satisfaction and Registered Nurse Perceptions” (Bozimowski, 2012). When pain is unrelieved, it can be a source of great distress and adversely affect patient satisfaction with pain management. This is important because assessing patient satisfaction has become a crucial means for the health care industry to measure success. Satisfaction with pain management is also required by the Centers for Medicaid and Medicare (CMS) as a measure of quality (Bozimowski, 2012). Results affect CMS payments to hospitals and are reported nationally. This measure is also reported by UMMC Nursing for Magnet re-designation. The main purpose of the Bozimowski (2012) study was to determine the value of utilizing a simple survey tool to measure patient satisfaction with pain management. Specifically, the author wanted to explore the impact of nurse perceptions of patient satisfaction with their pain management. The study sought to examine whether the regimen provided was congruent with patient self-reporting and to determine if the patient’s level of satisfaction corresponded to the type of pain therapy received. The study also included patient reporting of side effects experienced and an evaluation of whether there was a relationship between the patient’s report of adequate education and their satisfaction with pain management. Bozimowski (2012) conducted a pilot study utilizing a tool developed by the author to assess the current state of patient and nurse perceptions of satisfaction with pain management in the sample studied. The study enrolled a convenience sample of 50 patient subjects and the nurses who cared for them, and was divided equally between two medical-surgical units at a 150-bed community hospital. Patients were eligible for the study if they had a medical or surgical diagnosis and a nursing diagnosis related to the presence of pain. Patients participating in the study were asked to complete a short questionnaire. Patients were asked if they received adequate information about their pain management plan and whether they were provided with information regarding the advantages, disadvantages and limitations of their pain management plan. They were asked to rate their satisfaction with their pain management (with 1 indicating severe dissatisfaction, to 5 indicating very satisfied). If the patient reported dissatisfaction with their pain management, they were asked an additional question to identify their reason for dissatisfaction. Information about the most recent pain score (using a 0-10 numeric rating scale) and type of pain therapy was abstracted from the patient’s medical records. Nurses were then asked to determine the degree of satisfaction with pain management that their patient would report using the same Likert scale. The study provided a limited review of the literature consisting of select articles from 1996 to 2007. The concepts of patient satisfaction, pain efficacy and optimal pain management were reviewed but were not defined in the article. The literature review and the survey tool would have been improved by the inclusion of updated literature and the use of a conceptual framework that provided definitions of the concepts and their relationships. Study Findings The study findings were clearly described and easy to understand. Results indicated: ◗◗ Patients had moderate levels of pain (4.0 + 2.22) and satisfaction 3.8 + 0.881. ◗◗ Patients who had a higher level of last reported pain reported significantly lower levels of patient satisfaction with pain management. ◗◗ Patients who reported adequate teaching had higher levels of satisfaction compared to those who felt teaching was inadequate. ◗◗ Patients receiving PRN IV analgesia had a significantly higher last level of pain than patients on all other analgesia protocols combined into one comparison group (PCA, epidural, oral analgesia, and around-the-clock dosing). Although patients receiving PRN IV analgesia also reported lower levels of satisfaction, the results were not statistically significant. ◗◗ Nurses’ perceptions of their patients’ level of satisfaction with pain management were moderately, significantly correlated with patient reported levels of satisfaction. ◗◗ The unit with patients who reported significantly lower levels of satisfaction had significantly higher last pain ratings. Although not statistically significant, they were also more likely to report education was inadequate (52%) compared to 36%. ◗◗ Of the 13 patients reporting satisfaction levels < 3/10, 61.5% were surgical patients, 61.5% were receiving PRN IV analgesia, and 69.2% reported inadequate patient education (Bozimowski, 2012). continued on page 8. 8 Fall 2013 Pain Management, continued from page 7. Study Limitations A major study limitation was the absence of validity and reliability instrument testing. Therefore it is unclear whether the survey items contributed to the measurement of satisfaction. Lack of validity and reliability information also reduces confidence in the reported results. Confounding variables such as type and degree of patient pain and education were not assessed. The small sample size and lack of information about the subjects limit the generalizability of the findings. In the discussion, the author states that using the tool developed for this study to measure general satisfaction (as an indicator of satisfaction with pain management) is as useful as utilizing the Visual Analog Scale (VAS) for measuring pain management progress. He states this despite the following comments: First, he notes that patients report being satisfied even if they have high pain scores. This implies that pain is not the sole indicator of a patient’s satisfaction. Second, there was only a moderate correlation between satisfaction and last reported pain level. Third and most important, the study was not designed to test the stated premise. Group Discussion Despite the study limitations, the article brought about an enlightened discussion to include specifics to the work being conducted at the University of Maryland Medical Center (UMMC) to improve the patient experience with pain management. The discussion highlights are as follows: ◗◗ The group agreed that pain is subjective. Pain and pain relief can best be quantified through patient self-report; however, one person’s score of 10 is not the same as another person’s 10. Therefore, one can only compare scores for an individual patient, not between patients. ◗◗ Satisfaction with pain management at UMMC is moderately correlated to overall hospitalization satisfaction scores. Performance is better on the “staff doing all they can to manage pain” question versus the “pain is well managed” question in the HCAHPS survey. ◗◗ Based on the group’s clinical practice experience, they noted that addiction and the challenges of treating chronic pain could have impacted the findings. Capturing this information could have provided additional information on why people were dissatisfied. ◗◗ The group stressed the importance of obtaining accurate and honest histories from patients so that nurses can provide the best treatment. ◗◗ Nurses and patients tend to erroneously believe IV push meds are more effective than PO medications. However, efficacy may be improved by using oral medications, which are longer acting than IV push medications, and by using analgesics on a scheduled (around-the-clock) basis. ◗◗ Many factors contribute to patient satisfaction with pain management; however, a limited amount of research on how to improve pain satisfaction has been conducted as the majority of studies on pain management satisfaction are correlation studies. UMMC has seen improvements in pain satisfaction scores when a unit places emphasis on patient education and incorporating pain in patient rounds. Currently only 90% of patients have documentation of pain patient education on their chart. The UMMC Pain Committee is working on implementation of standardized adult and pediatric pain order sets. The order sets address PO meds administered around the clock based on severity of pain and include respiratory rate and sedation parameters. These orders will be similar to an insulin sliding scale to factor in that patients respond differently to pain medications. This will allow the nurse to individualize treatment plans while practicing within their scope of practice. Patients are free to refuse if medication is not needed. Summary At UMMC, the clinical staff understands that patient’s pain is a serious concern and that inadequate pain management may leave some patients feeling dissatisfied with their nursing care and their hospitalization in general. Pain screening is completed multiple times per day, and since changes to Powerchart, the effectiveness of interventions is completed at the time of approximate peak effect of the therapy. Nurses recognize the responsibility to improve patient perceptions of pain management, but may be unable to intervene independently with pharmacological agents. Enhanced communication with the care team and increased consultation with the pain service may result in actions that could improve pain management. Clinical staff is committed to ensuring a positive patient experience with pain management and will continue to investigate and implement best practices in order to achieve the desired outcomes. References Bozimowski G., (2012). Patient Perceptions of Pain Management Therapy: A Comparison of Real-Time Assessment of Patient Education and Satisfaction and registered Nurse Perceptions. American Pain Management Nursing 13 (4); pp. 186-193 Find News&Views online at http://www.umm.edu/nursing/newsletter.htm UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm news & views PATIENT CARE SERVICES | RESPIRATORY 9 UMMC Respiratory Care Ventilator 5K Christopher D. Kircher, MS, RRT, Associate Director, Respiratory Care Services and Maria Madden, BS, RRT, Supervisor, Respiratory Care Services For the past four years, the UMMC Respiratory Care Department has hosted teams to participate in the Ventilator 5K Race in support of the American Respiratory Care Foundation (ARCF). The ARCF works to promote and advance the respiratory care profession by providing scholarships for entry- and advanced-level practitioners in conjunction with the American Association for Respiratory Care (AARC). The Foundation hosts conferences and professional events to advance the development of new knowledge through research grants and fellowship opportunities to promote best practices. Since 1985, the ARCF has donated millions of dollars to these types of professional development and community benefit endeavors. The Ventilator 5K event is a national challenge to the respiratory care profession and supporting industry. Ventilator 5K funds can be accessed through grants to provide patient education, community support and other public health programs related to respiratory care. Over $3 million has been raised through this fun and energetic event. In the four years UMMC has participated, ARCF funds have returned to our community in support of two meaningful local programs: 1) Camp Superkids, a week-long residential summer camp for children with asthma; and to 2) Dr. Bob’s Place, a palliative care facility for children living with a life-threatening illness and for their families throughout the greater Baltimore/Washington area. The UMMC 5K event teams were recognized at the AARC National Congress both in 2010 and in 2012 with top fundraising honors. Following the 2012 race (and $4,500 in donations) a group of over 20 therapists representing several of the local hospitals was awarded a portable ventilator monitor, the Breathe NIOV Ventilation System, which was donated by Breath Technologies. In 2010, the prize was a portable ventilator, the Carina, donated by Drager Medical. After an assessment of internal needs, the UMMC Respiratory Department leadership has decided to donate both pieces of equipment to local respiratory care education programs for training purposes. At this year’s event, held on October 11, 2013, the five local participating hospital groups were joined by a new team. For the first time ever, a team of vendor representatives from our local area that provide respiratory services was able to participate! The Ventilator 5K race gains a fun reputation by requiring each team to dress in a themed costume and decorate an actual “ventilation device” that the team members push in relay fashion throughout the entire course. UMMC takes top honors at the 2012 AARC National Congress. Spirited competition and fun costumes have been part of every race. Since this year’s National Congress was held near Disney World in Anaheim, CA, the two UMMC teams dressed up as the 101 Dalmatians and the Skeleton Crew from an early Disney cartoon, “The Silly Symphony.” As in past years, many photos were taken to help celebrate the event and further promote Respiratory Care Week (October 20–26, 2013). Although the event’s primary goal is to raise money and to increase awareness of the ARCF’s many activities, the event has also generated great enthusiasm and team spirit among UMMC therapists. Participants have proudly represented the profession in promoting the event and successfully increasing participation in each of the four years the race has been held. The race has contributed to a huge increase in national exposure for UMMC and the other participating hospitals. The UMMC race videos have been highlighted on both YouTube and the AARC website. The fundraising success has also been noted in several professional magazines and the AARC National Congress’ official program publications. Diana Johnson, MS, PT, Director of Rehabilitation Services at UMMC, shares, “While winning the race is a wonderful accomplishment, the UMMC Respiratory Care Department seems more pleased about the ability of the department to raise needed funds to support the community we serve. The commitment of these professionals is inspiring.” Registered respiratory therapists (RRT) who participated during the 2013 race include: Jeff Ford, RRT, Director; Chris Kircher, RRT, Associate Director; Maria Madden, RRT; Rob Smith, RRT, Pete Saunders, RRT, and Hamid Reza, RRT, Supervisors; Matt Davis, RRT, Educator; and staff therapists Francine Jones, RRT, Kate Dolly, RRT, Melissa Thurber, RRT, Diamond Watson, CRT, Leticia Holyoke, RRT, Roberto Guanzon, RRT, Ryan Holt, RRT, Dennis Lee, RRT, Marissa Saunders, RRT, Colleen Githens, RRT, Judith Truelove, RRT, Jessica Linbarger-Bishop, RRT, Archana Patel, RRT, Nathan England, RRT, Brittany Rub, RRT, Daniel Whitt, RRT and Terry Goodwin, CRT. 10 Fall 2013 Magnet Submission, continued from page 1. changes. Examples such as the organizational response to the Alaris pump failures and the increased focus on civility were described in the Magnet documents as outcomes related to Dr. Rowen’s ongoing commitment to advocating for the concerns of direct care nurses. The CNO breakfast and lunch sessions and nurse leadership rounding were cited as additional avenues of access for direct care nurses to the CNO and other nurse leaders along with the biannual C2X forums. 3 The third section entitled Structural Empowerment (SE) focuses on how nurses at UMMC are involved in self-governance and are empowered to make decisions that impact nursing practice. This is accomplished through a robust shared governance council and through nurse involvement in organizational decision-making groups, such as councils, committees and task forces. Other components of empowerment include the Medical Center’s commitment to continuing education, and a description of how the Medical Center promotes certification and participation in professional organizations. This section also describes UMMC’s partnerships with various schools of nursing and with the community. In this section of the Magnet documents, UMMC’s continuing education benefits were described, including formal education through enrollment in degree programs as well as the generous annual reimbursement allowance for conference attendance and certification review courses and exams. The participation of nurses in professional organizations and the leadership positions that UMMC nurses hold within these organizations were also highlighted as an example of how nurses lead not only within UMMC but in the larger nursing community ORGANIZATIONAL OVERVIEW Kristin Seidl (r), and Rachel Hercenberg submit the UMMC Magnet application. The re-designation document is divided into five sections: Organizational Overview, Transformational Leadership, Structural Empowerment, Exemplary Professional Practice and New Knowledge, Improvement and Innovations. 1 The opening section or Organizational Overview provides a detailed explanation of the UMMC organization, describes how nursing is integrated into the organization’s strategic plan and how direct care nurses have a voice through the shared governance council structure. This section also contains unit-level detail about nurse satisfaction and nurse-sensitive quality outcomes such as patient satisfaction, infection rates, fall rates and pressure ulcer prevalence rates. Nursesensitive quality indicators reflect not only clinical outcomes, but the professionalism of UMMC nurses and the quality of care delivered. This section provides the appraisers with a general idea about what nursing at UMMC “looks like” and sets the stage so that they are able to make an objective assessment about the quality of nursing care as they read through the remaining sections of the document. 2 A second section entitled Transformational Leadership (TL) addresses strategic planning, advocacy and influence of leaders, as well as the visibility and accessibility of leaders. In practice, a transformational leader has a strong vision and philosophy, clearly communicates expectations, and develops future leaders. This section also describes how leaders guide staff through periods of change, such as moving units and new buildings, and how leaders strategically improve efficiency and effectiveness of the healthcare system. The implementation of lifeIMAGE® in the TRU was showcased in the Magnet documents as an example of how clinical leaders provided support to direct care nurses who worked to improve the efficiency of care delivery. lifeIMAGE® is a program that is best described as a ‘cloud’ for radiological image storing and viewing, and it allows uploading and viewing of images from transferred patients. Another requirement of this section is to provide a description of how input from direct care nurses is used to improve patient care and the work environment. The participation of staff in the shared governance council structure provides nurses with numerous opportunities to collaborate with leadership to affect change in practice and the work environment. At UMMC, the Staff Nurse Council (SNC) provides a great opportunity for direct care nurses to have regular face time with Lisa Rowen, DNSc, RN, FAAN, Senior Vice President of Patient Care Services and Chief Nursing Officer. In this forum, input is solicited and suggestions for improvements are made. Dr. Rowen and other nurse leaders then work to make meaningful 1 University of Maryland Medical Center Magnet® Re-designation Application August 1, 2013 ORGANIZATIONAL OVERVIEW ORGANIZATIONAL OVERVIEW 3 1 as well. Other stories highlighted in this section include the remarkable work of the multidisciplinary Transitional Care Coordination team in reducing hospital readmission rates and the work of psychiatry staff to decrease the use of restraint and seclusion use in all behavioral health settings. 4 The fourth section, called Exemplary Professional Practice (EP), is the biggest section of the application; 277 pages and 27 Sources of Evidence. It makes sense that this is the biggest section of the application because it speaks to how nursing is practiced, how nurses ensure the highest standards of care, and how UMMC supports nurses in the delivery of high quality care. This section first asks for a description of nurse involvement with developing the professional practice model and the outcomes associated with applying the model. This section is critical, as it describes how nurses are involved in the identification of the values and principles that define nursing practice and patient care delivery at UMMC. The components of the UMMC professional practice model, as conceptualized in the threads of “The Rope,” drive nursing strategic initiatives such as the professional advancement model and numerous projects (performance improvement, evidence-based practice, research) that are implemented news & views to improve patient care outcomes. The outcomes of this work are then shared across the organization through the articles published in News and Views and at Nursing Grand Rounds. The EP section also requires information about how quality and patient safety programs are operationalized. Important nursing priorities such as ensuring high-quality patient care across the healthcare continuum and participation in employee safety programs such as safe patient handling initiatives are described in this section. Other exemplary practice exemplars include a description of how the organization supports the caregiver in times of caregiver distress. For example, a description of the annual Pediatric Bereavement program and the annual Shock Trauma Memorial service were included in the Magnet documents, as was a description of the SICU debriefing protocol. A description and a copy of the poem that accompanies the Nurse’s Week tradition of “Blessing of the Hands” was also provided, and the Integrative Care Team was highlighted for their work with both patients and staff. Finally, the Exemplary Professional Practice section includes more data about nurse satisfaction, patient satisfaction and quality outcomes at the organizational level. The document highlighted that UMMC’s hospital-acquired pressure ulcer rate is exemplary, and in general, the CLABSI rate across all clinical areas has improved significantly over time and is now outperforming benchmarks in most units. It was shared in the document that although the inpatient fall rate is still over the benchmark when compared to fall rates in other academic medical centers, the rate is beginning to trend down in some care areas. TRANSFORMATIONAL LEADERSHIP TRANSFORMATIONAL LEADERSHIP 11 of evidence to practice included the implementation of hourly caring rounds, the standardization of neurological assessments for patients receiving high-dose Cytarabine in the Marlene and Stewart Greenebaum Cancer Center, and the development and implementation of a patient transport algorithm in the Medical IMC. Examples of innovations provided in the documents included the use of social media in patient support groups, the creation of an interactive game to teach patients about Coumadin, and the creation of the nurse-developed hand hygiene video that reminds us: “hands up, hands up, put your hands up to the pump.” This section also required specific detail about how direct care nurses are involved in new building design and space renovation. As one can imagine, there was a lot to say about new buildings, design and re-design in this application. From the new Critical Care Tower, to the expanded Adult ED, to the designing of a new NICU, nurses at UMMC had thoughtful and fantastic stories and details to share. The re-designation document has been reviewed and the ANCC has requested additional information from our organization. The supplemental documentation was due to the ANCC Magnet appraisers December 9th. The review of this information will take six to eight weeks. Once the document review is completed, the appraisers will make a recommendation to the ANCC whether there is sufficient evidence to warrant a site visit. If the Magnet requirements are met within a range of excellence, the appraisers will come to UMMC to verify, clarify and amplify what was submitted in the documents. The Magnet Team will keep everyone informed of the appraiser NEW KNOWLEDGE, INNOVATIONS, & IMPROVEMENTS NEW KNOWLEDGE, INNOVATIONS, & IMPROVEMENTS 2 3 STRUCTURAL EMPOWERMENT STRUCTURAL EMPOWERMENT 4 Y EXEMPLAR ACTICE PR L A N PROFESSIO PROFESSIO EXEMPLARY NAL PRAC TICE 5 1 1 1 1 A description of the UMMC CLABSI and CAUTI initiatives were described in detail, as was the fall prevention bundle and the remarkable results of units such as the Vascular Progressive Care Unit. Together, the 27 examples provided in this section represent the exemplary professional practice exhibited by UMMC nurses every day. 5 The final section of the application is called New Knowledge, Improvements and Innovation (NK). This section has nine Sources of Evidence and covers topics such as research- and evidence-based practice, as well as innovations in patient care delivery. Each completed an ongoing research study over the past four years was listed and briefly explained. The novel research around delirium prevalence and predictors of delirium in trauma patients was highlighted and described in detail. This section also requested examples of how evidence was translated to practice at UMMC. There were many examples to share. in the documents to include implementation of a “bundle” in the NICU that led to significant decreases in the incidence and severity of Retinopathy of Prematurity (ROP) in very-low-birthweight NICU babies, as well as a decreased incidence of hypothermia in very-low-birth-weight NICU babies. Other examples of translation findings as received. Once it is determined that the appraisers will be conducting a site visit, the re-designation documents will be made available for all staff to read. With the supplemental documents submitted, the fun part of the Magnet process can begin. The Magnet Champions are already busy working on preparing staff for a potential site visit early next year. See pages 12-13. Nurses who were employed at UMMC in 2009 may have memories of a site visit that was exciting and energizing! The re-designation site visit will be no different. The goal of the visit is for UMMC nurses and staff to celebrate and describe all of the great work that is occurring in the organization to improve patient care outcomes and the work environment. This is a time to recognize how UMMC staff is making a difference in the lives of the patients every day. Preparation will be focused on how to share these accomplishments while re-energizing members of the healthcare team. This will be the time to show your pride in the care we deliver — it is time to get re-Magnetized! 12 Fall 2013 Magnet Site Visit Prep Education for Nurses and UMMC Employees C2X Forums Flyer As mentioned on page 11 of the Magnet article, below are the educational materials developed by the Magnet Champions to prepare nursing staff and all employees for a potential site visit in early 2014. - - Top Ten Review Tips for Nurses 2013–2014 1. Understand the benefits of Magnet and why achieve? • Benefits: Recognition for excellence in nursing practice & professionalism, improved patient and nurse satisfaction, and reduced RN turnover. • Why??: The Magnet standards are evidence based and provide an effective framework to guide the development of environments committed to providing outstanding care. 2. Know the Magnet Model Components • Transformational Leadership: The CNO is a knowledgeable transformational leader who develops a strong vision and strategic/quality plans to lead nursing services. All nurses throughout the organization know that their voices are heard, their input is valued and they are supported in their practice. • Structural Empowerment: Decision making structure is flat, flexible and decentralized. Nurses are involved in shared governance and decision making processes. Community connections and professional development are promoted by the organization. Nurse contributions to the patients/ families/community are recognized. • Exemplary Professional Practice: The Professional Practice Model (The Rope) depicts how nurses practice, collaborate, communicate and develop professionally to provide the highest quality of care. The Care Delivery Model (RBC) is part of this model. Interdisciplinary collaboration is evident and is valued by the organization. Nurses practice autonomously to meet the unique needs of the patient and family. Culture of safety, quality monitoring and quality improvement is integral to achieving exemplary professional practice by nurses at all levels. • New Knowledge, Innovations and Improvements: Integration of EBP and Research into clinical/operational processes is consistent. Resources to support the advancement of EBP and Research are in place. Innovations in patient care, nursing and the practice environment are evident in the organization. • Empirical Outcomes: Organization and Consumer Outcomes that are nursing sensitive. Establish baselines for measures and track progress over time compared to the baseline and national benchmarks. (Nursing Sensitive Quality Indicators (NSQIs) examples: Falls, Pressure Ulcers, Catheter Associated UTIs (CAUTI), Central Line Associated Blood Stream Infection (CLABSI), Patient and Nurse Satisfaction, C-section Infection Rates) 3. Know the Shared Governance Council Structure and Processes for Decision Making (Structural Empowerment) • Governance occurs at the house-wide and unit level through the nursing governance councils (see model on back page). • The nursing governance structure allows nurses to be autonomous and involved in decision making about nursing practice. • Some examples include development/updates to policy and procedures based on EBP, change in workflow processes, implementation of patient safety measures (falls), staffing/scheduling, skill mix, equipment, supplies, and physical layout of unit. - 4. Know the UMMC Professional Practice Model – “THE ROPE” (Exemplary Professional Practice) • “The Rope” is our Professional Practice Model and represents how we practice as nurses at UMMC. • The model was developed by UMMC nursing staff. • The components of the model have been in place for quite some time at UMMC. • The strands represent values, structures and processes. • The rope becomes stronger when the strands are coiled together around the core of this model – The Patient and Family. • Our Care Delivery Model of Relationship Based Care (RBC) and our nursing governance structure (councils) are part of this model. UMMC Nursing Professional Practice Model Professional Standards (Yellow) ANA Scope & Standards, Maryland Nurse Practice Act, professional organizational standards, regulatory standards, ethical standards Patient Care Delivery (Blue) Relationship Based Care; Care Delivery across the Continuum; Evidence Based Practice Excellent and Safe Patient/Family Care Leadership and Governance (Red) Transformational leaders; shared governance structures Professional Values (Orange) Commitment to Excellence, UMMC Behavioral Standards, interprofessional collaboration, educational partnerships (UMNursing), community partnerships, healthy work environment Advancement of Nursing Practice (Green) Clinical inquiry (research, EBP and QI), professional advancement model, certifications, continuing education news & views 13 C2X Forums Flyer B t for the Magnet Mo bile okou o l e in 2 pions will be roundin h m t a h g to n 014 tC o e n h f f o f r the si e e all sta ag ! M are prep te vis i t. lp MAGNET DESIGNATION? Why achieve Top Ten Review Tips, continued from page 12 5. Know the difference between performance (PI), evidence based practice (EBP), and research (New improvement Knowledge, Innovations and basedImprovements) practice (EBP), and research (New Knowledge, Innovations and Improvements) PI or Process Improvement Purpose Theory/Model Data Evaluate current processes & plan improvements PDCA- (Plan, Do, Check, Act) Collect and evaluate data to measure processes and performance. Used internally Strategies to improve patient satisfaction: Hourly Caring Rounds EBP or Evidence Based Practice Problem solve a clinical practice issue Guided by models Review and evaluate existing data in the literature. Collect and analyze data post EBP implementation Drive clinical practice guidelines and procedures Most accurate method to verify large bore NG tube placement 5. Know the difference between performance improvement (PI), evidence Research 9. Get ready the for appraisers – comfortable Site visit TBD (Feb – March 2014) It isfor critical you to feel talking about your accomplishments • It is critical for you to comfortable talking your accomplishments and showing offfeel your units. Practice these about conversations before the actual MAGNET DESIGNATION? and showing offin your units. Practice before the actual site site visit your unit huddles, inthese smallconversations groups and with the Magnet Champions during rounds with the roving cart!! visit in your unit huddles, in small groups and MAGNETude with the Magnet Engage and greet the with appraisers as soon as they walk oncart!! the units. Champions during rounds the roving MAGNETude the appraisers your unit brag books and talkon about • Engage Show and greet the appraisers as soon as they walk thethem. units. Show the appraisers yourbrag process improvements and other data. • Show the appraisers your unit books and talk about them. 10. Bethe proud and enthusiastic • Show appraisers your process improvements and other data. 10. Be proud andpractice enthusiastic nursing and professionalism. • Show your pride and passion for nursing and talkyou about the MAGNET IS ABOUT YOU!!! Share how make a difference. excellence in nursing practice and professionalism. • MAGNET IS ABOUT YOU!!! Share how you make a difference. Show your pride and passion for nursing and talk about the excellence in 9. Get ready for the appraisers – Site visit TBD- (Jan or Feb 2014) Why achieve Results Example at UMMC Generate new knowledge or test an intervention Based on scientific theory Collect and analyze using rigorous statistical methods to test research hypotheses Published or formally presented Hemolysis of blood samples in ED Examples on my Unit/Dept 6. Know your nurse sensitive quality indicator data andand thethe national benchmarks 6. Know your nurse sensitive quality indicator data national • Thesebenchmarks indicators reflect the effectiveness of nursing care. • They include falls, pressure ulcers, patient satisfaction (pain, These indicators reflect the effectiveness of nursing care.education, & overall), nurse satisfaction, staffing,ulcers, and skill mix. They include falls, pressure patient satisfaction (pain, education, & overall), nurseand satisfaction, staffing, and mix.what it means. • Data must be current you must be able toskill discuss Datainvolvement must be current youplans must be to discuss what it means. • Discuss your in and action to able improve the data. Remember the Discuss your involvement action plans to improve the data. Remember goal for falls, pressure ulcers, and in BSIs is 0%. 7. Know how the Nursing Officer (CNO), Lisa Rowen, 7. Know howChief the Chief Nursing Officer (CNO), Lisa Rowen,and and other leaders leaders are visible, advocate for nursing, and include in decision are visible, advocate for nursing, and include you inyou decision makingmaking (Examples: CNO Unit Rounds, PCS Lunches with CNO, (Examples: CNO Unit Rounds, PCS Lunches with CNO, Staff Staff Nurse Nurse Council) Council) 8. Describe how UMMC supports advanced education, involvement in professional organizations, certification, and community involvement professional organizations, certification, and community involvement Costs, Professional (Examples: Financial Support for Certification (Examples: Financial Support for Costs, Professional Organization Memberships andCertification Conferences, Tuition Reimbursement, for School Schedules) Time off to attend Conferences, Flexible Scheduling Organization Memberships and Conferences, Tuition Reimbursement, Time off to attend Conferences, Flexible Scheduling for School Schedules) 8. Describe how UMMC supports advanced education, involvement in the goal for falls, pressure ulcers, and BSIs is 0 %. 14 Fall 2013 CLINICAL INFORMATICS UMMC’s Journey toward Achieving Meaningful Use Shanna Hartman, BSN, RN, Nurse Informaticist, UMMC Department of Clinical Informatics Today more than ever, government mandates are shaping the way in which healthcare providers deliver care. In 2004, President Bush established a goal for every American to have an electronic health record (EHR) by 2014. To facilitate this initiative, the Health Information Technology for Economic and Clinical Health (HITECH) Act was established in 2009. This act allocated $27 billion as incentives from the Centers for Medicare and Medicaid Services (CMS) for hospitals and physicians who are “meaningful users” of an EHR system by January 2015. The act also enforces penalties for those who are noncompliant by this date6. The use of an EHR encourages patients to be engaged in their care, refines care coordination between patients and providers, and improves quality and safety of the care they receive2. Meaningful Use (MU), a federally mandated program as part of the HITECH Act, is federally mandated and is designed to promote patient safety and improve outcomes with the use of a certified EHR. Incentive payments are made to eligible professionals (EP), eligible hospitals (EH), and critical-access hospitals (CAH) by meeting set percentage goals for objectives and measures as determined by CMS3. There are currently three Stages to the MU program. Stage 1, year 1 is for those beginning the MU journey which requires a 90-day reporting period. Stage 1 year 2 involves a full year of reporting. There are more rigorous guidelines and higher percentage goals as organizations and providers enter Stage 2. Stage 2 requires that all data, objective measures and clinical quality measures (CQM) come exclusively from the EHR and not from other third-party vendor data systems. Stage 2 requires that hospitals provide patients with the ability to view, download and transmit health information via access to a patient portal 2. It is expected that Stage 3 will go into effect in early 2016; however, the criteria have not been developed yet by the CMS 3. The University of Maryland Medical Center (UMMC), is currently completing Stage 1 year 1 by submitting the 90-day initial report using the current Cerner-certified HER 2. All Stage 1 criteria listed below must be met for both the 90 day initial reporting period and the Stage 1 year 2 reporting period. In order for UMMC to meet the Stage 1 requirements, documentation changes within Cerner applications have been necessary. Although the organization is actively transitioning to Epic for the clinical and business systems, UMMC leadership recognized the importance of undertaking this project prior to the EPIC implementation for patient care and financial reasons. As of February 2013, there have been 3,757 hospitals enrolled to participate in meaningful use and CMS has paid out $200 million to these hospitals 4. At UMMC, changes and upgrades to Cerner are being made to not only meet meaningful use criteria, but also to allow improved clinical documentation and reporting prior to the EPIC go-live. For example, members of the Stroke Team currently manually abstract all patient data on stroke patients to report to CMS. The stroke registry will soon electronically capture and report all of their data. This will allow providers and clinicians more time with the patients and less time abstracting data from paper charts. As clinicians endure the challenges of change, they must wonder “what’s in it for us?” As leaders of this change, the EPIC team sees continued on page 15. STAGE 1 MEANINGFUL USE CRITERIA Computerized provider order entry (CPOE) Drug-drug and drug-allergy interaction checks Recording patient demographics Clinical decision support Up-to-date problem list of diagnosis Active medication list Active medication allergy list Charting vital signs Recording smoking status Reporting hospital CQM Providing patients with electronic copy of health information upon request Providing electronic copy of discharge instructions upon request Protecting electronic health information news & views I Was Noticed The I Was Noticed Program, a long standing program sponsored by the C2X Employee Engagement Team, provides opportunities for patients, family members, and staff to recognize UMMC staff who are doing something great. “I Was Noticed” cards are located throughout the Medical Center and they can both be placed in an “I Was Noticed” box or faxed to 8-1880. Cards are entered in a monthly drawing and eligible employees win “free” vacation time! The Employee Engagement Team aims to recognize 36 employees annually. Listed are the winners from August and September of 2013. August Katrina Hoadley, CNII I/P Perinatal Gyn “Going above and beyond on a busy morning in the nursery. Thanks for discharging a baby in the midst of the busy morning! Great for patient satisfaction.” from Sharon Betz Mary Howard, Medical Assistant 15 September Fatou Ba, Surgical Support Tech Integrated Tech Support, Periop Services “Thank you very much for all that you do for our Cardiac Service. Your hard work delivering our blood, blood gases, and turning over our ORs is seen, felt, and appreciated on a daily basis!” from Mayumi Verona UWB: Waxter “Great Job! Your service and stewardship while the office experienced a staff shortage. You were very efficient and we truly appreciate your hard work. from Tynnetta Davlon Magda Wardrop-Truesdale, CNII Sandra Simpson, CNII I/P Perinatal Gyn “Thanks for being an awesome charge nurse on a busy, crazy night. You are such an awesome team player” from Abby Keller Mary Lou Briggs, CNII Geropsychiatric I/P “Magda has been recognized by a former patient and another patient’s family member for dedication and hard work. Letters and flowers arrived for Magda. She offers support and education for her patients and families.” from Nancy Hedden Child Inpt 4G “Thank you sooo much for helping Friday morning figuring out lab orders and communicating. You were a huge help. Always a pleasure to work with you.” from Megan Hagen “Thanks for being a preceptor to new employees, performing in service training, and orienting new staff to policies, procedure, and documentation. You demonstrate the ability to provide leadership in complex assignments, strong organizational and customer service skills, and always promote teamwork! Positive role model!” from Kimberly Johnson Achieving Meaningful Use, continued from page 14. many future benefits for front-line users. At the bedside, documentation and clinical care can be streamlined from admission to discharge and across the continuum with the use of an EHR. As UMMC develops an all-encompassing system, integration of computerized provider order entry, barcode medication administration, electronic documentation, and electronic discharge information will allow bedside clinicians to provide more structured and efficient care. By accurately documenting care that impacts patient outcomes, data will be more readily available to monitor quality and improve patient outcomes 5. It is critical that caregivers at all levels understand that the documentation changes have a purpose: continued improvement of our already high-quality patient care. Reimbursement is always a significant driver of change, but the true purpose of meaningfully using the EHR is enhanced patient care, outcomes and safety 1. In the future, the EHR will contain information about the full continuum of care for patients at UMMC and throughout the University of Maryland Medical System (UMMS). Currently, patient care information does not transfer system-wide within UMMS. An integrated clinical information system will help improve patient safety and the quality of care. Providers will be able to view patient records from services received at other hospitals, clinics and provider offices that share the UMMS Epic platform. Patient access to their health records will support improved coordination of care with a secure method for patients to view labs, medications and schedule appointments. With vigilance and improved clinical electronic documentation, UMMC has the potential to receive $3.5 million in financial incentives. More importantly, these changes will enhance the care UMMC delivers to patients. Changing workflows in order to streamline and facilitate clinical documentation will have benefits for all — the organization, the clinicians and ultimately the patients! References 1 Baker, J.D. (2013). “Meaningful use”: A call to action. Association of Perioperative Registered Nurses, 97 (6), 607-609. 2 Centers for Medicare & Medicaid Services (CMS) (2010). Medicare & Medicaid EHR incentive program. Retrieved from http://www.cms.gov/Regulations-and-Guidance/ Legislation/EHRIncentivePrograms/Downloads/MU_Stage1_ReqOverview.pdf 3 Centers for Medicare & Medicaid Services (CMS) (2013). Meaningful use. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/Meaningful_Use.html 4 Mosquera, M. (2013). CMS: Meaningful use HER incentives hit $12.3B in February. Government Health IT. Retrieved from http://www.govhealthit.com/news/cmsmeaningful-use-ehr-incentives-hit-123b-february 5 Pope, K.R. (2013). Data czars: Meaningful use and the role of the nurse informaticist. Harbingers of Health Care Information Technology. 28(1), 11-13. 6 Schilling, B. (2011). The federal government has put billions into promoting electronic health record use: How is it going? The Commonwealth Fund: Quality Matters. Retrieved from http://www.commonwealthfund.org/Newsletters/QualityMatters/2011/June-July-2011/In-Focus.aspx 16 Fall 2013 PATIENT CARE SERVICES | DIETETIC INTERNSHIP The UMMC Dietetic Internship (DI) Program: Educating Future Nutrition Practitioners Ellen Loreck, MS, RD, Director of Clinical Nutrition Services, Dietetic Internship Director One of the FY 14-17 Strategic Plan goals at University of Maryland Medical Center (UMMC) is to: “develop an atmosphere, in partnership with all affiliated Schools, that prepares learners to meet future care delivery demands, while addressing the workforce needs of the region.” In support of the strategic plan, the Department of Clinical Nutrition at UMMC is fortunate to have a training program in place for soon-to-be registered dietitians (RDs) that aligns quite well with this goal. This program supports exposure of UMMC dietetic interns to many areas of the organization. Each intern has the opportunity to meet many patients, family members and employees. The interns can be found throughout the medical center and surrounding areas: on patient care units with their RD preceptors; at a Step Up to Good Health Program; teaching nutrition principles to UMMC staff; or at the Farmers’ Market, helping Baltimore City school children make good food choices. The following reviews general facts about dietetic internship (DI) training programs and what makes the UMMC DI unique. What is a Dietetic Internship Program? A Dietetic Internship Program is a post-baccalaureate program that provides a supervised practice experience after students have completed their required academic coursework. Currently, entry into practice for dietitians requires a bachelor’s degree; however, the profession is working towards making a Master’s degree entry level. Once interns complete all DI requirements, they are eligible to take the exam for registered dietitians (RDs). In the state of Maryland, licensure is also required to practice as a registered dietitian. All DIs operate under the Accreditation Council for Education in Nutrition and Dietetics (ACEND), the accrediting body for the Academy of Nutrition and Dietetics, and must demonstrate compliance with 23 standards. This year, UMMC completed a five-year program assessment report and will have a site visit by ACEND surveyors in four more years. Of note, DI programs are highly competitive; in April 2013, only 48% of applicants matched with a program. How is the UMMC Dietetic Internship Program Structured? The UMMC DI is a clinically focused, 10-month program, with an emphasis on distilling evidence-based nutrition practice within a team environment. UMMC accepts four interns each year from an application pool of 50 to 75, and interns progress through the program in pairs. The UMMC RD preceptor team teaches clinical nutrition practice concepts in a stepwise progression during the course of a 27-week clinical rotation which occurs on the UMMC campus. The clinical rotations begin with cardiac nutrition and diabetes; the mid-point rotations are nutrition support (enteral and parenteral nutrition) and the culminating experience is a four-week staff relief experience during which the intern functions as an entry-level RD, with preceptor oversight. In addition to the clinical rotations, interns complete a fiveweek food service and management rotation with the Department of Food and Hospitality Services, a three-week community rotation in a variety of settings, one week in clinical nutrition management and a one-week elective. What Makes the UMMC DI Unique? Of the 248 DI programs in the US, UMMC’s program is one of only 49 programs housed within a hospital setting. UMMC, an innovative academic medical center, is the perfect setting for a DI program with a clinical focus. At UMMC, we have 25 Registered Dietitians with inpatient and outpatient responsibilities. Each team member possesses continued on page 23. Right: Kids to Farmers Market Program (Joint UMMC/University of Maryland, Baltimore initiative) Below: Teaching at the Step Up to Good Health session Above: Maryland Academy of Nutrition & Dietetics Annual Meeting: Poster presentation from Step Up to Good Health lecture to UMMC employees news & views Healing Arts Exhibit for Employees & Families By Rachel Hercenberg, MS, Project Specialist, Clinical Practice & Professional Development & Healing Arts Team Lead 17 The 1st Annual University of Maryland Medical Center (UMMC) Healing Arts Exhibit for Employees and Families was a huge success. From October 9–23, 2013, 156 pieces of artwork lined the UMMC hallways. All art was created by UMMC employees, physicians, and their family members. On October 9th, local judges Robert McClintock, Will Williams and Cinder Hypki selected the winners of 21 awards, many of whom received cash prizes sponsored by the National Arts Program. BEST IN SHOW Shannice Wollcock (Relative of Ian Wollcock, MS, IT Systems Support, Information Service and Technology): “Alone” ADULT PROFESSIONAL 1 PLACE: Deborah Kommalan (Relative of Marnie Kommalan, RN, SCN I, Peri-operative Services): “President Street Parking” ST 3RD PLACE: Jonathan Gottlieb, MD, Senior Vice President and Chief Medical Officer: “Death Valley” HONORABLE MENTION: Laurie Bennett, MS, Applications Systems Analyst III, IS&T: “Blue Still” TEEN (12-18 years old) 1ST PLACE: Jamie Bernstein, Age 16 (Relative of Wendy Bernstein, Associate Professor, Anesthesiology): “A Visit to the National Gallery” 2ND PLACE: Julie Kearney, Age 15 (Relative of Sarah Woodring, BSN, RN, SCN I, Medical IMC): “Merry Marigolds” 3RD PLACE: Kylie Bryant, Age 15 (Relative of Jennifer Bryant (MRI Radiographer II, Radiology): “Still Life” HONORABLE MENTION: Elin Fan, Age 13 (Relative of Xiping Ma, MS, BSN, RN, CN II, Cardiac Care Unit): “Origami Miniatures” CHILD (12 and under) 1ST PLACE: Diana Isabella Olivo, Age 8 (Relative of Icelsa Garcia, Facilities Planner, Facilities Planning & Development): “Fruits Table” 2ND PLACE: Joshua Cignatta, Age 12 (Relative of Dennis Cignatta, RN, CN II, Cardiac Surgery Stepdown): “Flower” 3RD PLACE: Rivka Manangan, Age 11 (Relative of Rona Manangan, Medical Lab Associate II, Laboratory): “Sunflower” HONORABLE MENTION: Mya Allen, Age 8 (Relative of Nichole Allen, Outpatient Coder Team Leader, Health Information): “Mama’s Loveseat” PEOPLE’S CHOICE AWARD Danielle Deckard, LGSW, Social Worker, Social Work; Amateur; “Underwater Sunshine” 2ND PLACE: Lynn Hamrick, BS, HT (QIHC), Histopathology Tech, Anatomic Pathology: “Waiting for Jack” 3RD PLACE: John Cotterell, RN, CN II, Neurology Clinic: “Easter” HONORABLE MENTION: Sami Gurmu, Special Projects Coordinator, Patient Experience C2X: “Healing Energy” ADULT INTERMEDIATE 1ST PLACE: Darron Claiborne, MS, Senior Quality and Compliance Coordinator, Safety and Quality/Cancer Center: “The Avenue” 2ND PLACE: Tina Patterson, Activation/FFE Manager, Project Development: “P4-STC-R” 3RD PLACE: Rupal Mehta, MD, Assistant Professor, Pathology: “Traffic” HONORABLE MENTION: Alexandra Clemsen, Cardiac Sonographer, Cardiology: “Laugh” ADULT AMATEUR 1ST PLACE: Tammy Blyveis, Medical Lab Specialist II, Hematology: “Coy Koi” 2ND PLACE: Napoleon Reyes (Relative of Hydelyn Grace Cerbo, RN, Discharge Facilitator, 11 East): “Tulip” 18 Fall 2013 Spotlight on Pharmacy Apoteca Chemotherapy Robot Jennifer Nishioka, PharmD, BCOP, Oncology Pharmacy Manager, BMT Clinical Specialist “To err is human, but errors can be prevented.”1 If you consider all types of medication errors, the average hospital patient will be subjected to more than one medication error per day.2 A minimum of 7,000 deaths in the US each year are attributed to preventable medication errors,1 with chemotherapy errors ranked as the second most common cause of fatal medication errors.3 Chemotherapy errors present a unique challenge as these agents have a very narrow therapeutic window and significant toxicity profile. Even the smallest discrepancy in a dose may have serious deleterious effects in a patient population that is already compromised. Although the risks of an overdosage are clear, the risks of an underdosage should never be underestimated. Suboptimal dosing could affect the overall efficacy of the regimen and give less than optimal results. The integration of technology into the compounding aspect of chemotherapy is an obvious next step in improving patient safety. In January 2012, University of Maryland Medical Center (UMMC) implemented Dose Edge technology for the preparation of chemotherapy. This technology uses bar code scanning for correct product identification and high-resolution cameras for viewing each preparation step. Although this has greatly improved accuracy rates, drug measurement and dose checking is still a manual process subject to human error. On June 24, 2013, UMMC became the third medical center in the United States to install the Apoteca chemotherapy robot (APOTECAchemo), a fully automated robotic system for the preparation of hazardous medications. Although this technology has been in use in Europe since 2007, there are only two other US medical centers with the Apoteca: Cleveland Clinic (July, 2011) and Wake Forest Baptist Medical Center (November, 2012). APOTECAchemo is a completely self-contained negative pressure cabinet that fully automates the compounding process using a six-axis robotic arm. The cabinet contains a rotating carousel capable of holding nine doses of chemotherapy to increase efficiency, an agitator for reconstitution of lyophilized powders, and a highprecision scale for weighing all raw ingredients and final products. The Apoteca uses bar code technology to correctly identify all intermediate and final products. It can manipulate 5mL, 20mL, and 60mL syringes, prepare IV bags up to 1000mL, and will soon be able to prepare elastomeric pumps. All orders are transmitted electronically to eliminate transcription errors. The Apoteca provides several advantages over manual preparation. Each vial is entered into the system by an Apoteca technician using a minimum of 70 different data points. This information is used not only for drug identification, such as the drug’s density and NDC (national drug code), but for manipulation of the vial by the robotic arm (dimensions of the vial). Every drug and diluent is identified by barcode and optical recognition. There are a series of safety check points throughout the drug preparation process in which a parameter of the vial loaded for compounding is matched against that of the vial with the same NDC in the Apoteca database. If there are any discrepancies, the vial is rejected. 1. Height of the vial(s): Optical recognition and bar code scanning: Each vial of drug has the bar code read and is optically scanned. The photo(s) are matched against those in the Apoteca database. 2. Weight—Correct drug: The weight of each unused vial is measured and compared to the weight entered for that NDC. If they do not match, the vial is rejected. 3. Correct dose: Each dose and corresponding volume to inject is calculated using the drug’s density. The Apoteca will weigh the vial before and after drug is withdrawn and using the drug’s density, calculate if the correct amount has been drawn up for that dose. The Apoteca will adjust the quantity and reweigh if necessary. 4. Verification of final preparation: Once the preparation is complete, the final product is weighed to ensure that it falls within a pre-established expected weight range for a given preparation. If the final weight is out of this range, the Apoteca will reject the dose and quarantine it for inspection by a pharmacist. Upon inspection of the dose, preparation records, and variance report, the pharmacist may accept or reject the dose. continued on page 21. news & views Certification Corner Certifications Soar in Pediatrics with the “No Pass, No Pay” Program Bridgette C. Casserly, MS, RN-BC, CPN, Senior Clinical Nurse I, Acute Care Pediatrics 19 Pediatric nurses are eligible to sit for the Certified Pediatric Nurse (CPN) exam after completing 1,800 hours of pediatric nursing practice; however, personal financial barriers may prohibit some employees from taking the exam. At the University of Maryland Medical Center (UMMC), achieving national nursing certification is valued and promoted. One year ago, the Medical Center made the commitment to simplify the exam-taking process for its pediatric nurses. UMMC partnered with the Pediatric Nursing Certification Board (PNCB) to offer UMMC pediatric nurses the“No Pass, No Pay” Program. This program reduces the personal financial barriers by eliminating the initial registration fees that were required prior to taking the exam. With the new agreement, if an RN does not pass the CPN exam, neither the individual nor the hospital is billed for the exam, and the nurse is allowed to take the exam again, which encourages nurses to do so as the PNCB absorbs the application fee if the nurse is unsuccessful. Once an RN successfully passes the exam, PNCB bills the Medical Center for the exam registration fees, which are covered under the employee’s continuing education reimbursement benefits. The first contract period for this partnership, which occurred from October 1, 2012 through September 30, 2013, required that 10 nurses sit for the exam during the 12-month period. UMMC had 24 nurses sit for the exam, an incredible response. To date, 19 of these nurses have passed and are now Certified Pediatric Nurses. Fifteen of these nurses are employed in Acute Care Pediatrics and four are employed in the Pediatric ICU. Due to the success of the “No Pass, No Pay” program, the contract has been renewed for another year as of October 1, 2013. The pediatric leadership team hopes that the second year of the program will be met with comparable excitement and success. (If you are a nurse with 1,800 hours of pediatric nursing experience in the last 24 months and are interested in testing for the CPN exam, please contact email@example.com for more information.) Programs like this are now being offered for other nursing certification exams, and all nurses are encouraged to contact their specialty certification body for details. The PNCB makes it possible for hospitals across the country to offer this benefit to their pediatric nurses. Sharing information on this program with the pediatric nursing community is encouraged. This partnership with the PNCB exemplifies UMMC’s commitment to supporting nursing certification and creating a culture of excellence. The elimination of out-ofpocket fees and charges for failed exams has effectively removed the financial barriers that were once obstacles for many pediatric nurses. This program is a great benefit to UMMC’s pediatric nursing staff and has enabled certification numbers to soar! Patient Care Technicians Pass Certification Exam Patricia Wilson, BSN, RN, FCN, Clinical Education Specialist, Clinical Practice and Professional Development The University of Maryland Medical Center (UMMC) celebrates 30 patient care technicians who passed the CPCT (Certification for Patient Care Technicians) examination. The patient care technicians are graduates of the IT Works Learning Center, Inc., which is a career training center that trains certified nursing assistants to become patient care technicians. UMMC’s partnership with IT Works, Inc., has resulted in many patient care technicians who have successfully transitioned into the Medical Center’s workforce. In preparation for the examination, the students participate in an eight-hour review course offered by the IT Works Learning Center, Inc. The CPCT exam is a nationally recognized measure of competency. The CPCT National Allied Health certification enables the patient care technician to: ◗◗ Demonstrate a commitment to the chosen profession ◗◗ Improve career opportunities and advancement ◗◗ Demonstrate expertise in the skills performed ◗◗ Develop a sense of professionalism ◗◗ Demonstrate being an integral member of the health care team The Certified Patient Care Technician partners with nurses to provide direct patient care in a variety of clinical settings at the Medical Center. The CPCT performs delegated patient care functions utilizing skills which have been formally validated. A CPCT may perform some or all of the following tasks as delegated under the direct supervision of a Registered Nurse and in accordance with the nursing care plan: ◗◗ Monitor vital signs and perform blood glucose checks ◗◗ Assist with activities of daily living, including bathing, feeding and performing oral hygiene ◗◗ Change bed linens and process dirty linens properly ◗◗ Perform patient safety checks to keep patient rooms clean and clutter free ◗◗ Turn and reposition patients, toilet and ambulate patients ◗◗ Maintain clear paths in hallways – clear and return equipment that is no longer in use ◗◗ Perform urinary bladder catheterization for temporary or permanent placement and implement catheter care in stable patients as delegated by the registered nurse ◗◗ Acquire and distribute patient care supplies ◗◗ Perform stage I and stage II dressing changes ◗◗ Perform phlebotomy and intravenous procedures ◗◗ Set up and operate multiple lead EKG machines; attach and remove EKG leads; run a rhythm strip. Professional certification is valued by the Medical Center because it demonstrates tangible evidence of skills and knowledge. Certification extends beyond training by providing an objective measurement of a professional’s competence in a specific area of practice standards. This plays an important role in developing a qualified workforce. PCTs are a valuable asset to the nursing care team at UMMC and we are proud to support this achievement. UMMC congratulates these 30 PCTs who were successful in achieving their certification! 20 Fall 2013 AMBULATORY SERVICES Implementation of the ARC Framework in Treating Traumatic Stress in Adults and Children in the Ambulatory Psychiatry Clinics at UMMC Mary Tlasek-Wolfson, MScN, RN, CS, Ambulatory Psychiatry Clinic Manager; April Donohue, PhD., Child Clinical Psychologist, Ambulatory Psychiatry Clinic; Miranda Kofeldt, PhD., Adult Clinical Psychologist, Ambulatory Psychiatry Clinic and Laura Anderson, PhD., Adult Clinical Psychologist, Ambulatory Psychiatry Clinic Trauma can result from experiences of violence. Trauma impacts relationships with self, others, communities, and environment, often resulting in recurring feelings of shame, guilt, rage, isolation, and disconnection. However, healing is possible. The Child and Adult Psychiatry services at UMMC see many trauma patients. As an effort to best serve this population, our Child and Adult teams initiated training in June 2012 to incorporate a trauma-informed care delivery model. This article serves as Part 1 with a focus on efforts in the ambulatory setting. A future article will focus on implementation of trauma informed care in the acute care setting. More than 2,000 patients, or 35%, of the annual visits to the Ambulatory Psychiatry Clinics at the University of Maryland Medical Center (UMMC) are seen as part of the established follow up in the Trauma Clinic. These patients have histories that may include physical, emotional and sexual abuse, possibly with exposure to community violence, neglect and socioeconomic deprivation. Many are diagnosed with Post Traumatic Stress Disorder subsequent to abuse and/ or exposure to violence. For some, this is often accompanied by additional psychiatric disorders. An example of typical patient case history is as follows: Honey* is an 8 year old who lives with her parents. Both parents are known to the mental health and child welfare systems. Honey’s parents were reared in foster care prior to when they met and were married. Honey’s father suffers from bipolar disorder and often loses his temper. When her father loses his temper, he turns his anger onto Honey. Honey and her mother have spent time at a domestic violence center in the past. Honey has begun to have difficulties in school, where she displays emotional outbursts that cause many of the teachers to refuse to have Honey in their classrooms. Honey’s expression is rather flat, and she typically withdraws from confrontation. She is failing third grade. * Honey is not an actual patient. To better address the needs of patients and families with situations like Honey’s, and to better manage the effects of multiple childhood trauma and the associated risks, the Psychiatric Outpatient Clinics recently incorporated the Attachment, Self-Regulation, and Competency (ARC) Framework (Kinniburgh, Blaustein, Spinazzola, van der Kolk, 2005) into their behavioral health care delivery model Repeated chronic trauma has a significant impact on one’s ability to appropriately deal with the physiological, emotional, behavioral, and cognitive experience. This framework aligns interventions with target behaviors within three broad domains of attachment, self-regulation and competency. Each domain has building blocks or key treatment targets (see Figure 1). Figure 1. Building Blocks of Attachment, Self-Regulation, and Competency from Treating Traumatic Stress in Children and Adolescents p. 36, by M. Blaustein & K. Kinniburgh, 2010, New York: The Guildford Press. The key treatment target has identified goals, interventions and applications that take into account developmental and cultural considerations. The attachment building blocks emphasize the relationship between the child and the caregiver in conjunction with developing skills to foster this relationship. Strategies revolve around trust and the parent not feeling ineffective. The self-regulation blocks emphasize the identification and awareness of emotions and safely sharing those feelings with others. The competency blocks emphasize the building of internal and external resources to be able to positively function socially, academically and within the community at large. Strategies employed give emphasis to normalizing feelings, and highlighting safe versus unsafe expression of feelings (Kinniburgh, Blaustein, Spinazzola, & van der Kolk, 2005). In June 2012, an interdisciplinary group within UMMC’s Adult and Child Ambulatory Psychiatry Clinics participated in a two-day ARC training program followed by six monthly supervisory sessions with a “developer” who is a psychologist. The child team presented continued on page 21. news & views ARC Framework for treating traumatic Stress, continued from page 20. difficult cases to this developer to ensure interventions consistent with the framework were employed. The adult team also presented difficult cases to a different psychologist who is a content expert in adult trauma and attended the workshops with the child team as well. Trauma-informed care is now an integral part of the treatment program in both the Adult and Child Outpatient Psychiatric setting. Child and Adult clinicians formed a workgroup to review reliable and valid tools to be implemented to measure outcomes with the implementation of the ARC framework. Each newly admitted patient is screened for exposure to trauma, and those with a positive screening complete a more thorough trauma evaluation with a clinician. Their symptoms and response to treatment are measured every six months with reliable and valid questionnaires. The tools selected assess both adult and child behaviors and feelings that are reflective of attachment, self-regulation, and competency. Patients like Honey and her parents bring both strengths and suffering to UMMCâ€™s clinic. The ARC Framework supports working with the patient and family to deal with the layers of stress each has been subjected to over time. The Medical Center staff has the ultimate goal of building healthy connections between the patient and their family while supporting each individual to develop the ultimate sense that they are successfully healing. References Blaustein, M., & Kinniburgh, K. (2010). Treating traumatic stress in children and adolescents. New York: The Guildford Press. 21 Laura Anderson, April Donohue, Miranda Kofeldt, and Mary-Tlasek Wolfson Kinniburgh, K., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2005). Attachment, self-regulation, and competency: A comprehensive intervention framework for children with complex trauma. Psychiatric Annuals, 35(5), 424-430. Apoteca Robot, continued from page 18. The Apoteca provides safety benefits to the operator as well as to the patient. Preparation of hazardous medications in an enclosed negative pressure cabinet by a robotic arm minimizes handling of drug vials and needles by the operator. Additionally, all waste is automatically disposed of into sealed hazardous waste containers reducing occupational exposure and environmental contamination. Safety is always the top priority, but the Apoteca also has the potential to increase productivity and utilize resources more effectively. Preparation times for a single vial of drug in solution are faster than that of humans with recorded times of 100 seconds for a syringe (vs. 180 seconds manually) and 145 seconds for an IV bag (vs. 180-300 seconds manually). Lyophilized powders will take longer to prepare, however the Apoteca is equipped with an agitator and has the capability of reconstituting vials. The system helps reduce waste by tracking open vials by their expiration date for re-use and storing the open vials inside the robot for easy access. Although the carousel can hold up to nine doses loaded in advance (three vials per dose), it can not be left unattended as each completed dose must be manually unloaded before the robot can begin preparing the next dose. This does, however, allow the technician to complete other tasks while the robot is compounding. As the pharmacy continues to integrate the Apoteca into daily routines, workflow at UMMC is optimized as the robotâ€™s productivity increases. Currently, the robot can prepare 25-30 doses per day, or approximately 25% of the daily workload. This is an expected output at this point in the implementation and is at par with our US counterparts. Several variables that affect productivity with the Apoteca are: availability of chemotherapy orders in advance, drug and IV bag shortages, and the different types, sizes, and shapes of vials that are currently available from the different manufacturers. The Apoteca is not compatible with all vial types and selection of product must be made with input from the Apoteca technician and the purchaser. Although the integration of robotics into a historically manual process can be challenging, the added patient safety benefits are worth it. The Apoteca robot was made possible through a generous gift from Roslyn and Leonard Stoler. The Stolers have named the Apoteca in honor of their granddaughter, Lindsay, and we are very pleased to have this wonderful addition to the team. The pharmacy would like to say a special thank you to the Stolers for their longstanding commitment to improving the lives of those affected by cancer and for giving UMMC the opportunity to work with innovative technology that will truly change the future of oncology. References 1 Institute of Medicine (IOM). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. 2 Institute of Medicine (IOM). Preventing Medication Errors. Washington, DC: National Academy Press; 2006. Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY, Pamer C: Retrospective analysis of mortalities associated with medication error. Am J Health Syst Pharm 2001, 58:1835-1834. 3 22 Fall 2013 Compassion and Excellence – “The Angel Award” One Patient’s Experience Leads to Big Things the impact their actions had on Mr. Nooney, they each said something very similar — “It’s just what we do.” Even though these two nurses viewed this behavior as their normal practice, it was not viewed as ordinary to Mr. Nooney. Being sick and coming into a new hospital in a big city is He needed their compassion and patience. He realized that their scary enough; getting a devastating diagnosis is petrifying. confidence in the care team quickly led him to feel confident as well. This is exactly how Mr. Jim Nooney’s UMMC story He said, “These two gave me a handle to hold onto as I pulled myself began. Before coming to UMMC, Mr. Nooney started his forward into the reality of having cancer.” It was a turning point for him. This man, who had been a champion of heroes across our state, journey in his “home town” hospital, Atlantic General, on had no idea how much he would need his own hero at just the right Maryland’s Eastern Shore. Mr. Nooney’s symptoms were moment to face his own challenges. puzzling his primary physician, who suggested that he see a It did not take long for Mr. Nooney to call his dear friends who doctor at UMMC. helped found the Maryland Troopers Foundation, Mr. Bernie Shaw and Mr. Robert Devers. He expressed to them his desire to recognize the two angels who helped him bridge the Just two days after making the call, gap between wellness and fear of Mr. Nooney was admitted to 13 East/ the unknown. This is when “The West Medicine Telemetry under the Angel Award” was conceptualized. care of UMMC’s GI Team. To make a He quickly took his plan to Borkoski long story short, doctors at UMMC to gain hospital approval and then to brainstormed collectively, ran some the Maryland Troopers Foundation tests, performed a few procedures, for development and support. and discovered a tumor that was On October 11, 2013, Mr. sitting precariously against a major Nooney, a very grateful group of artery leading to his pancreas. It friends and family, along with staff was not an easy tumor to find. In and physicians who have cared fact, several days of negative testing for Mr. Nooney across his journey, motivated the team to continue gathered to recognize Sheldon looking for the source of Mr. Nooney’s and DiMarcantinio with the first symptoms and pain. Jim Nooney, Erin DiMarcantonio and Lindsey Sheldon Compassion and Excellence; The Mr. Nooney describes the first Angel Award reception. Mr. Nooney few hours (after awakening from the and the Maryland Troopers Foundation graciously donated the first procedure that definitively diagnosed this tumor) in a way that is both $1,000 for this award so that Sheldon and DiMarcantonio would receive terrifying and comforting. When he first awakened from anesthesia, $500 each to use for educational activities to enhance their practice. white coats surrounded him, and he thought, “Wow, I’ve died and Continuing fundraising efforts by the Maryland Troopers Foundation and gone to heaven, and this is the choir singing me through the pearly Mr. Nooney will be sent directly to the University of Maryland Medical gates.” In fact, it was a dedicated team of physicians and other care Center Chief Nursing Officer (CNO) Fund, within the University of providers, ready to share their findings, and describe the first stages of Maryland Medical System Foundation, for future support of this award. a complicated treatment plan that would take several days to finalize — The award criteria and the selection process will be further developed a plan Mr. Nooney would have to agree to in very short order. in the near future by a team formed through the department of Patient The first emotions he describes include fear — of both the Experience. The award’s goal is to recognize bedside care providers known and unknown — and confusion about needing to make very who exemplify compassion and excellence, and those that help patients difficult decisions. Lying in a hospital bed, still a bit woozy from manage their diagnosis and emotional journeys. anesthesia and facing a wide array of stimuli was, at the very least, There are moments in a nurse’s career that are remembered overwhelming. Jim’s wife, Melanie, who is a nurse, was at his bedside, fondly with emotion and gratitude. These are the special moments trying to make sense of such a devastating diagnosis. His fear was that define the “WHY?” of what nurses do every day and allow nurses balanced by the work of two nurses who cared for him in those very to reflect on why they choose nursing as a profession. These two troubling hours – two nurses he calls his “angels.” Lindsey Sheldon, nurses had the opportunity to experience the gratitude of one patient BSN, RN, CMSRN, Clinical Nurse II, 13 East/West Medicine Telemetry while they, and so many other nurses, touch so many lives every day. and Erin DiMarcantonio, BSN, RN, CMSRN, Clinical Nurse II, 13 East/ Being recognized in this way with the creation of “The Angel Award” West Medicine Telemetry were assigned to care for Mr. Nooney on is very special and something these two nurses will remember forever. consecutive shifts on this fateful afternoon and night. When asked, “Why Nursing?” for these two nurses, their response In telling his story, Mr. Nooney describes his emotional turmoil, is simply: to care, to heal and to watch over the patients in our care. but he quickly begins to smile as he remembers the compassion and When providing care to Mr. Nooney, they did not think they were caring that Sheldon and DiMarcantonio shared so easily with him. He doing anything extraordinary. They were just providing compassionate clearly remembers the way they supported his emotions, in ways that nursing care to a patient in need. Congratulations to Lindsey Sheldon, they do not even remember doing. When Ruth Borkoski, BSN, RN, and Erin DiMarcantonio, the first recipients of The Angel Award. Nurse Manager of 13 East/West Medicine Telemetry, shared with them Kerry Sobol, MBA, RN, Director Patient Experience and C2X and Tina Cafeo, DNP, MSN, Director of Medical and Surgical Nursing news & views Dietetic Internship, continued from page 16. unique professional strengths and talents, which they share with the interns. The UMMC preceptor team has multiple specialty certifications: Certified Nutrition Support Clinician (CNSC), Certified Specialist in Renal Nutrition (CSR), Certified Specialist in Pediatric Nutrition (CSP), Certified Specialist in Oncology Nutrition (CSO) and Certified Diabetes Educator (CDE). In addition to the RD team, UMMC also has an excellent team of clinical dietetic technicians (DTs) who perform on-going nutrition risk screening and other supportive roles. The interns learn about how the DT/RD team work together to manage the nutrition care of our varied patient populations. In addition to completing their rotation requirements, the interns are exposed to some of the unique aspects of patient care at UMMC. Interns have observed multiple surgeries (i.e.: kidney transplant, cardiac bypass) and procedures, such as feeding tube placement and modified barium swallow exams with UMMC’s Speech-Language Pathology therapists. How Does UMMC Benefit? The fact that the internships are so competitive helps Clinical Nutrition recruit the “best of the best,” with the goal of offering these interns permanent positions upon program completion. Approximately one third of the UMMC RD staff members are graduates of our DI program. The program provides the team with 10 months to “interview” an intern, and if they are hired, it allows orientation to be significantly reduced. Considering the acuity level of UMMC’s patient population, it is a major benefit to onboard new hires whom have been trained on site. In addition, while in the DI program, interns get the experience of being team member in a dynamic academic medical center, providing them numerous opportunities to impart their growing nutrition knowledge with others. They have created displays for employees and community health fairs; developed a nutrition presentation to help staff eat healthier at work; created a theme meal in the Café to educate staff about healthier options; and have written nutrition blogs for the Baltimore Sun. Last but not least, having dietetic interns keeps UMMC’s current clinical team sharp; UMMC RDs make sure to remain current with their practices, in order to teach cutting-edge practices to others. From a clinical nutrition perspective, UMMC’s DI prepares interns to meet future care delivery demand in an acute-care environment, while addressing the workforce needs at the Medical Center. To learn more about the UMMC DI, go to: http://umm.edu/professionals/dietetic-internship 23 Would you like to have your article published in News&Views ? Submitted articles should: • Present clinical and professional nursing practice topics in inpatient, procedural and ambulatory areas that are evidence-based, innovative, and outcomes driven. • Focus on divisional, departmental and/or organizational strategic goals. See page 2 for submission guidelines. teaM ManageMent of diaBetes March 11, 2014 save the date University of Maryland BaltiMore soUthern ManageMent Corporation CaMpUs Center 621 W. Lombard Street baLtimore, md 21201 22 South Greene Street Baltimore, Maryland 21201 www.umm.edu Clinical Practice Update Vaccine Update Patient Assessment October 2, 2013 Deferral status: An updated Vaccine Assessment is required for ALL patients who are admitted – o For patients under Observation status who are later admitted - the assessment is required even if patient remains boarded in an ED or PACU. Check the Immunizations Tab to see if the patient has received: o Pneumococcal vaccine any time in the past. o Influenza vaccine during the current flu season while at UMMC If patient is unable to answer (or does not remember): o Check patient’s past medical history when answering inclusion criteria for pneumococcal vaccine. o If patient unable to indicate vaccine status - ask the patient’s family or refer to documentation from other facilities. Note: deferral criteria for febrile or critically ill Shock Trauma ICU patients is only temporaryo Vaccine status must be reassessed when the patient no longer meets the deferral criteria, or prior to discharge When patient no longer meets deferral criteria, use a new vaccine assessment tool (found in Adhoc charting) Record of Administration: Document vaccine administration on the E-MAR as either “given” or “not given” Document a reason why the vaccine is not given on the E-mar (refused, had in the past, etc) NEW: Document the provider’s reason for temporary delay in administering vaccine in E-MAR progress note (Ad Hoc Charting). Document provider name and reason for delay. Vaccine is to be administered when criteria for temporary delay no longer applies. Ask provider to discontinue the order for vaccine if provider does not want the patient to receive the vaccine during this admission. Use the Quality Dashboard to determine if the patient has an outstanding vaccine assessment. Call the HELP desk if there are problems with the vaccine assessment tools, the vaccines on the E-MAR or problems with the vaccines column on the quality dashboard. Do not use the “No Inclusions” selection for Pneumococcal vaccine in patients who meet the age or high risk diagnostic criteria! Do not use the “Critically Ill Shock Trauma Patient” status if you are not in a Trauma ICU. Do not leave vaccine assessment deferred until discharge – vaccine status must be reassessed prior to discharge (unless patient has expired). Do not document on E-MAR that vaccine is “not appropriate at this time” – this completes the task and renders it unavailable for completion at a later time. Do not document on E-MAR that provider did not want patient to receive the vaccine. Request that they discontinue the order. Please Avoid the Following: Contact Patty Dumler at firstname.lastname@example.org for questions or additional information.