news views Spring 2013
A Publication of the Department of Nursing and Patient Care Services
University of Maryland Medical Center
I Am a Boston Marathon Nurse Alexander E. Halstead, BSN, RN, CCRN, Clinical Nurse II, Surgical Intensive Care Unit
Editor’s Note: There are no words to accurately describe the personal and physical devastations that resulted from the bombings at the 2013 Boston Marathon. Several Medical Center staff participated as runners and miraculously avoided physical trauma, although the emotional scars will remain for a life time. In addition, UMMC was honored that one of our nurses from the Surgical Intensive Care Unit, Alexander E. Halstead, BSN, RN, CCRN, Clinical Nurse II, acted as a medical volunteer for the marathon. Halstead has received local and state recognition for his heroic involvement on the UMM.edu website and on WBAL-TV, an NBC-affiliated Maryland television station. The account of this tragic day is provided in the following story. On April 14, 2013, I hopped onto a northbound plane to return home to Boston to see family and again volunteer my services for one of the biggest events of the year. I am a marathon nurse. That doesn’t mean I run the marathon. I volunteer to provide medical care to runners after they finish the race. This was my fourth consecutive year with the Boston Marathon. I grew up in Framingham, MA, so the Boston Marathon has always been part of my life. I started volunteering while still in nursing school at the University of Massachusetts in Amherst. I also worked as an EMT on campus, and in the ER at Baystate Medical Center in Springfield. Soon after graduating, I moved to Baltimore to embrace an opportunity to work in the Surgical ICU at the University of Maryland Medical Center. However, I always go back to volunteer for the Boston Marathon. On Sunday, April 14, the day before this year’s marathon, I went out to breakfast with my family, caught up with old friends, and rested up for the exhausting day that was to follow. Marathon Monday! I arrived in downtown Boston to prepare for my day. As in previous years, I spent the morning with my fellow volunteers and some of Boston’s leading sports medicine physicians, who gave us valuable information for treating runners. They explained the treatment protocols and some of the ailments we might come across. We picked up our marathon jackets and we were dismissed to get lunch. Boston does marathon medicine right! The medical tents are massive air-conditioned structures with televisions, hundreds of cots, a laboratory section, and multiple other resources. We prepared our respective sections of the tent to receive runners. Each section was made up of a physician, a few nurses, a physical therapist, and a few podiatrists – a truly well-rounded medical team. The cheering began as the wheelchair winners were the first to cross the finish line, and some of them passed through our tent on their way to the Copley Square Hotel. Soon after, the men and women elite runners walked through the tent after their amazing feat – usually needing minimal care because they train so well. At 12:30 p.m., the runners started trickling in as patients. The high predicted temperature was 54 degrees, so we expected a slow day in the tent. In my section, we saw runners for a continued on page 15.
Lisa Rowen’s Rounds:
Vascular Surgery Progressive Care Unit Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services
The Vascular Surgery Progressive Care Unit is aptly named – it is, indeed, progressive. Whether it is a new initiative to increase hand hygiene, increase staff ownership or decrease patient falls, or simply approaching any challenge with a can-do attitude, this unit is innovative and engaged. The staff members’ enthusiasm and positivity are infectious. Their desire and efforts to continuously improve patient care extend well beyond the walls of their unit. Please read on to understand why I have chosen the Vascular Surgery Progressive Care Unit, also known as Gudelsky 5 East (C5E), to receive the annual CNO Team Award for Extraordinary Care. I arrived on C5E during Quiet Hour, which occurs daily from 1 to 2 pm and 1 to 2 am. The lights were dimmed and the voices were hushed. Virginia Nganga, BSN, RN, Senior Clinical Nurse I, explained Quiet Hour was initiated in January to address patient complaints of noise on the unit interfering with their rest. Breaking the silence, a bed alarm rang. Every single staff member, including the nurse manager, Simone Odwin-Jenkins, MBA, BSN, RN, started sprinting to the room where the alarm was sounding. The reason was not
continued on page 6.
In This Issue 1 1 2 3 4 5 7 8 8 11 12 14 15 16 17 18 19 20 22 24
I Am a Boston Marathon Nurse Lisa Rowen’s Rounds Corporate Compliance CRISP for Our Patients Informatics & The Epic Project Role of the Ambulatory Nurse UMMC Healing Arts Exhibit Core Measures Improving Vascular Outpatient Flow you&ummc: Welcoming New Nurses Nurses Week 2013 We Discover Certification Corner Improving Pain Management NNPs in the Neonatal ICU Nursing Governance Restructure Spotlight on Pharmacy Patient Family-Centered Care Honorable Mention Clinical Practice Update
Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer Toya Jackson, Director of Compliance
The Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) in each issue of News and 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 email@example.com or firstname.lastname@example.org. Compliance FAQ Q: Does HIPAA allow me to speak with the family or friend of a patient who is incapacitated or experiencing an emergency? A: Generally yes, as long as the patient has not expressly restricted information from being discussed with a particular person. If the patient is deemed incapacitated or is experiencing an emergency, HIPAA allows for professional judgment in allowing providers to speak with family and friends
about care, if it is in the best interest of the patient. Some examples of this would be assisting with health history, current condition, discharge, or follow-up appointments, etc. It would also be allowed in order to assist the hospital in receiving payment for services rendered.
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
Anne E. Naunton, MS, RN-BC Professional Development Coordinator Clinical Practice and Professional Development Editorial Board
Susan S. Carey, MS Professional Development Coordinator Clinical Practice and Professional Development Mary Ellen Connolly, MS, CPNP Pediatrics Suzanne Leiter Executive Assistant to the Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice, Professional Development, Neuroscience, Behavioral Health and Supplemental Staffing Lisa Rowen, DNSc, RN, FAAN Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services Mihae Shin-Diep, MS, CRNP Interventional Radiology
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
professional nursing practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines
Send completed articles via e-mail to email@example.com. 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 Summer 2013 Fall 2013 Winter 2014 Spring 2014
Due Date July 8, 2013 October 7, 2013 January 6, 2014 May 12, 2014
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.”
news &views Chesapeake Regional Information System for our Patients (CRISP) Cheryl C. Williams, MSN, RNC-NIC, MBA, Nurse Informaticist, Clinical Informatics & The EPIC Project
If you will, imagine the following scenario as an example. Jane Doe is employed at ABC Facility, Inc. She was not feeling well when she arrived to work. Shortly after arrival, Jane was found unconscious in the staff rest room by a co-worker. When the EMTs arrived, no one was able to give a description of what happened or report on Jane’s medical history. She arrived at University of Maryland Medical Center via ambulance and was unable to give the caregiver any information. As a provider of nurse caring for the patient, you are able to quickly access her medical health history and use that information to help diagnose and treat her condition. Where did this important information come from … a health information exchange called CRISP. Today’s healthcare arena is plagued with a staggering influx of patients who often go to multiple providers to receive care. This practice often leads to unnecessary repeated lab work, radiologic testing, conflicted prescription orders, and backlogs in ERs and physician offices. The lack of knowledge of past medical history can lead to higher risks to patient safety, increase in healthcare costs, and the reduction in a provider’s available time to treat critical cases. In 2009, through an effort to minimize cost, time, and improve patient safety, the Maryland Healthcare Commission designated Chesapeake Regional Information System for our Patients (CRISP) as Maryland’s statewide Health Information Exchange (HIE). The mandate for CRISP is to electronically connect all healthcare providers in the state of Maryland. The question at hand is why would the process of contributing and utilizing an HIE be beneficial to providers? A Health Information Exchange is the technology that supports the flow of health information among physician practices, hospitals, labs, radiology centers, and other healthcare institutions. In the state of Maryland, there are 46 acute care hospitals, each agreeing to work with CRISP in sharing patient data. Data points include patient demographics, lab results, radiology reports, and electronic reports. Currently, the Medical Center shares patient demographics and electronic reports with the system. CRISP offers a free web-based portal to access patient data through the HIE. Information can be printed and incorporated into records, which allow physicians and support staff to query patients for whom they are providing care. There is also the ability to view lab results, radiology reports, and other transcribed documents for that patient. Clinical information shared with CRISP is made accessible in real time. The electronic exchange of data provides: ◗◗ A more complete view of the patient. ◗◗ Improved efficiency, as less time is spent locating previous records and logging into multiple data sources. ◗◗ Enhanced reimbursement leveraged through electronic patient records and e-prescribing, which will soon be federally mandated. ◗◗ Coordinated care, as clinicians are able to view patient encounters from other providers. ◗◗ Access to real time clinical information from all CRISP participants that includes lab results, radiology reports, discharge summaries, history and physical information, consultations, and operative notes.
Care providers can become authorized users of CRISP in four easy steps: 1. Complete an online user request form at www.hie.crisphealth.org 2. Complete the CRISP training via an online WebEx session. 3. Submit a photo ID. 4. Be verified by the point of contact in the organization. Once all of the above conditions are met, CRISP will email a username and password directly. Additional benefits of CRISP include the Encounter Notification System (ENS) and direct messaging. ENS is a real time alert of when a patient is admitted to the hospital. Real-time information allows providers the opportunity to closely track their patient population. Tracking information includes patient admissions, intra-facility transfers, and discharges in the state of Maryland. Direct secure messaging can be used to communicate referrals and visit summaries between ambulatory practices, to send clinical information between ambulatory practices and hospitals, to make formal request for medical records, and to receive encounter alerts from the CRISP ENS. CRISP benefits the patient by improving the care delivery process. Patients may be seen more quickly. Diagnosis and interventions may be more effective through provider access to both real time and historical clinical data. Readily available results may decrease the need for duplicate tests and procedures and may reduce medical mistakes and unnecessary costs. UMMC and other Maryland acute care facilities have chosen CRISP to improve patient safety, minimize healthcare costs, and save time. For more information on CRISP, please visit www.crisphealth.org.
Informatics & The Epic Project … Sailing into Portfolio Brooke L. Gaskins, MS, RN, CNL, Nurse Informaticist, Clinical Informatics & The Epic Project
On March 11, 2013, UMMC held its kick-off event to introduce Epic Portfolio, an integrated electronic medical record, which will take the Medical Center into a new era of electronic documentation. What is EPIC Portfolio? EPIC is a state-of-the art integrated electronic information system that combines many aspects of a patient’s medical history into a single application. A medical record in Epic Portfolio will include data from participating ambulatory, outpatient, and inpatient records, resulting in a more comprehensive medical record. This will improve a clinician’s ability to treat patients based on complete and updated information. Regardless of the location of care, inpatient or outpatient, providers will be able to document in the same system. Most importantly, patients will have one integrated medical record that can be accessed and continuously updated, whether they are in the ICU or in an outpatient setting. Clinicians will be able to view the patient’s medical history, allergies, current medications, all test results, and progress notes as soon as they are available. Portfolio will allow providers to communicate directly with other physicians about a patient, and even place orders remotely 24 hours a day, enhancing patient care delivery. Once the system is fully implemented, patient information will be seamlessly integrated and freely flowing between the University of Maryland Medical Center, Baltimore Washington Medical Center, University of Maryland St. Joseph Medical Center, University of Maryland Medical Center Midtown Campus, and Kernan. Stages of the Implementation Process Stage 1: Planning and Discovery is the phase in which the Clinical Informatics team and Information Services and Technology (IS&T) work closely to define the project plan and timeline, determine project scope, define the project governance structure and key participants, assess current workflow, and conduct introductory discovery sessions and site visits.
Stage 2: Validation is the phase in which the team verifies workflows and compares them to the EPIC Portfolio build. Workflows that do not fit the build of EPIC Portfolio will be flagged. These disparities will be addressed through collaboration and joint decision making with the Clinical Informatics team, IS&T, and key stakeholders. Clinicians from each service line will be brought together to provide feedback on processes and workflows that will be reflected in the Portfolio build. Stage 3: Build occurs when IS&T builds or develops the system. Analysts program the system and configure it to look and function as directed by clinicians. Some examples of build include amending the appearance of flow sheets to meet the needs of unique clinical areas. Stage 4: Testing and Training is a multi-step process. Users perform unit testing of specific applications on their respective units. Integrated testing is conducted to ensure all applications in the system are working as a whole. Usability labs are held to allow experts from clinical units to test the system for ease of use. Experts navigate the system as they would in daily practice to detect problems with the design and build. Finally, all staff will attend Portfolio training in preparation for the go-live. Stage 5: Go-Live is the long-awaited event when the system is turned on and each of the hospitals begins using the applications. Round-the-clock unit support is provided. Super-users are available on the units to assist staff in real time and are in constant communication with the IS&T command center to address staff questions and concerns. Stage 6: Optimization takes place after implementation. The implementation timeline is aggressive, resulting in a basic system at onset. After go-live, additional applications will be brought on line and existing applications will be modified and refined based on clinician input after a period of use to create an optimized or more robust system. continued on page 5. Benjamin Laughton MBA, MSN, CRNP Senior Director, Clinical Informatics & The Epic Project
news &views The Role of the Ambulatory Nurse Joji Patterson, BSN, RN, Nurse Manager, Neurology Ambulatory Center Monika Bauman, MSN, RN, Nurse Manager, Women’s and Children’s Ambulatory Services
Ambulatory Care is a unique, specialized field of nursing that spans various clinical settings within UMMC, including outpatient clinics, procedural areas, infusion centers, and transitional care. In addition to expertise in ambulatory care, nurses practice in diverse and multifaceted subspecialty roles within neurology, otolaryngology, oncology, pediatrics, diabetes/endocrinology, cardiology, HIV/ infectious disease, surgery, urology, gastroenterology, transplant, radiology, women’s health, and psychiatry. Relationship-based care is at the core of ambulatory nursing practice at the Medical Center, as it continues from an inpatient level of care to the outpatient arena. This care delivery model emphasizes the development of collaborative relationships as one of the foundations to provide excellent patient care. The ambulatory nurse practices collaboratively with the physician, social work services, rehabilitation services, home care agency, and community organizations to address the needs of the patient and caregiver. As patients seek care for health related problems or seek assistance with health maintenance and/or health promotion, ambulatory nurses must be uniquely qualified as well as autonomous providers of patient care. Communication between the nurse and the patient may take the form of a visit and/or telephone encounters, with emphasis on educating the patient and family towards selfefficacy to manage symptoms of acute and/or chronic conditions and maximize wellness. Sometimes the emphasis is on assisting the patient and family to obtain insurance authorization for access to medication or treatment, finding resources for the underinsured, and coordinating care services.
continued from page 4.
How will EPIC Portfolio benefit the University of Maryland Medical System? ◗◗ Improve patient safety and quality of care by providing a single secure electronic record ◗◗ Provide a comprehensive approach to the complex issues of safe and effective medication use ◗◗ Route diagnostic testing results to the appropriate caregivers in a timely manner ◗◗ Allow for secure communication with patients to include access to lab results, medication refills, and scheduling of appointments ◗◗ Improve communication within offices and between environments of care – office to office and hospital to office ◗◗ Help nurses organize their work to ensure that patient care activities are provided across all disciplines and shifts ◗◗ Assist the hospitals with registering patients, managing the inpatient stay, and billing for services.1
Telehealth nursing practice within ambulatory is unique and presents its own challenges. Nurses must be versed with their scope of practice and the use of evidence-based resources to manage the patient through telephone triage. For example, astute interviewing skills with the application of the nursing process and critical thinking skills are essential in the management of a patient without the customary face-to-face encounter. The role of the ambulatory nurse is evolving in response to the many initiatives of healthcare reform. The need for nurses to be in the forefront of health promotion and disease prevention is evident, as the complexity of patients seen requiring extensive patient and family education is greater. With the changing healthcare landscape, the ambulatory nurse is emerging with an expanded role that is responsive to patient care across the continuum, with the goal of improving patient outcomes and averting patient readmission. Ambulatory nurses are in the forefront to ensure continuity of care and coordination of services as the patient flows from inpatient discharge to entry in the outpatient setting to a return to the community. The interest in ambulatory nursing at the Medical Center continues to grow as a specialty area, and more nurses are pursuing this practice setting for professional employment. The Ambulatory Professional Development Council (PDC) conducted a survey across the ambulatory clinical specialties and found the following characteristics: ◗◗ Educational background - BSN 68%; MSN 26% ◗◗ Academic Enrollment - 13% ◗◗ Advanced Certification - 24% The ambulatory PDC is actively communicating professional development opportunities to ambulatory nurses. The goal is to promote the professional advancement of the ambulatory nurse. If you would like additional information about the unique field of ambulatory nursing, visit the American Academy of Ambulatory Care Nursing at www.aaacn.org. Additionally, the advanced certification examination in ambulatory care is administered by the American Nurses Credentialing Center, and information is provided at www.nursecredentialing.org.
The implementation of EPIC applications will span both inpatient and outpatient areas. Each application has a unique name specific to the area of focus: ◗◗ ASAP (Emergency Department) ◗◗ Clinical Documentation (Inpatient) ◗◗ OpTime (Operating Room) ◗◗ Radiant (Radiology) ◗◗ Stork (L&D, Mother/Baby) ◗◗ Willow (Pharmacy) ◗◗ Security (Access) ◗◗ Cadence (Scheduling) ◗◗ Clarity (Reports) ◗◗ HIM (Health Information Management) ◗◗ Prelude (Bed Management) The execution of the EPIC system will be a massive undertaking and will touch every employee within the Medical System. However, with the input and support from the UMMS team, this will surely be a successful EPIC adventure! For more information, please feel free to contact the Clinical Informatics team at ClincalInformatics@umm.edu. 1
Yale New Haven Health System. Yale New Haven Hospital. 2011. https://projectepic.ynhh.org/Pages/FAQs.aspx (accessed 3/9/13).
continued from page 1.
to silence the alarm but rather to ensure the patient would not fall. The staff members on C5E take falls seriously and personally. They all feel accountability for their patients’ fall data and each of them can tell you how many days have gone by without a patient fall. The staff members used several strategies that led to success in reducing the number of falls on C5E from an average of 15 falls per quarter to three falls per quarter. About 18 months ago, Virginia led a small group to create a Falls Board (see below) that tracks each day of the month; highlights the number of days without a fall; offers falls updates; lists the protocol in the event of a fall and a tool for a postfall huddle; provides goals and expected outcomes, action plans and interventions; and lists the members of the Falls Committee. As of March 31, the team and patients had gone 62 days without a fall – great work! In addition, the team on C5E performs a huddle twice a day. During these huddles, they discuss: ◗◗ Falls: High-risk patients are identified, specific interventions are listed and they double check to ensure the bed alarm is on. ◗◗ Wounds: High-risk patients are identified and someone checks to ensure the wound/ostomy nurse has seen these patients; the medical record for every wound is checked to ensure a dressing order is written and performed with consistency. ◗◗ Urinary Catheters: All catheters are assessed to determine if they are still required or can be discontinued (per protocol). ◗◗ Central Lines: All central lines are assessed to determine whether they can be discontinued (per order). ◗◗ Drips: All drips are quickly listed; times for the next PTT are mentioned. ◗◗ Walking Buddy: Another innovation! The C5E team uses a huddle worksheet that is included with this rounding report.
The Walking Buddy is a new, joint initiative on C5E with our colleagues from Rehabilitation Services. Eight nurses and patient care techs have been trained by the Rehab staff in a Train the Trainer program, which has a goal of mobilizing the patients earlier in their hospitalization. As most of the patients on the unit are on the Vascular Surgery Service, early and safe mobilization is important for their recovery. The 8 Mobility Champions have been trained on lifts and gait belts and have a goal of safely getting patients out of bed every day by 11 am. As the remainder of the staff members are trained, they will no longer need to wait for a rehab therapist to mobilize their patients for the first time out of bed following a surgical procedure. This initiative has just started, and the Mobility Task Force will start tracking metrics to study compliance with their goals and whether earlier discharges occur from the intervention. As I heard about this initiative, I asked, “How is it possible that you all are involved in so many innovative processes?” Virginia replied, “Simone pushes us. We all write our goals and she enforces that a timeline is placed on our work.” I responded with a question: “Do you have even more goals as a team then what we’ve discussed?” Absolutely! Virginia shared C5E’s new goal of 100% Med-Surg certification for all of the nurses. To achieve this lofty goal, the nurses have formed a study group and are reviewing all of the systems, one session at a time. Katrina Daye-Whitehead, BSN, RN, PCCN, Clinical Nurse II, is the chair and champion of the certification initiative. All C5E staff members, regardless of role, are expected to be a member or leader of a unit-based committee. Members vote on the chairs of their many unit-based committees. Once elected, the committee chair campaigns for staff members to join that committee. It is a competitive process to engage their colleagues for their committees and they enthusiastically appeal to others to join. Victoria Phelps, BSN, RN-BC, Senior Clinical Nurse I, created a “campaign poster” to invite colleagues to join the Quality and Safety Committee. Talk about staff engagement! In addition, one of the committees is totally focused on employee engagement. The C5E C2X committee, chaired by Darlene Bonner, BSN, RN, Clinical Nurse II, celebrates special events, such as staff birthdays, years of service and awards received. For example, the C2X Committee sponsored the Employee Recognition Board in the staff break room. Bing Casal, BSN, RN, Senior Clinical Nurse I, is pictured for receiving the Certificate of Distinction for Outstanding Unit Leader from the Philippine Nurses Association and Biljana Brkic, RN, Clinical Nurse II and Nana Musa, BSN, RN, Clinical Nurse II, are pictured on this board for their years-of-service recognition. Darlene explained the team is planning celebrations during Nurses Week and Administrative Assistants Day, April 24. They will also recommend names of colleagues to Simone for a unit-based Employee of the Month. During this month, the C2X committee is focusing on NDNQI data and patient satisfaction via HCAHPS data. Of the past five months, C5E has scored above the Medical Center and national average for patient satisfaction. The staff is clearly doing many things the right way and you can sense it in their attitudes about their work and each other. The teamwork and care for each other is palpable on C5E. Fredin Pallikal, RN, Clinical Nurse II, has been on the unit for two years. He said, “I love this unit. The staff are great and very supportive. We see a variety of patients and it’s always interesting.” continued on page 10.
1st annual national arts prograM®
uMMC healing arts exhibit FOr EmplOYEEs & FAmiliEs
Calling all artistically talented staff and their family members! UMMC’s newest C2X team, the Healing Arts Team, has partnered with the National Arts Program® to host our first employee art exhibition and awards reception at UMMC (22 South Greene Street, Baltimore, MD 21201). The Healing Arts Team exists to provide opportunities for integrating art into your daily lives, using art as a forum for growth, self-expression and healing.
Mark your Calendars! registration: Now – August 23 via The National Arts Program® website www.umm.edu/arts
artwork drop off: October 3 – 4 • 7 – 10 am & 3 – 6 pm All participants will be contacted via email with drop off locations
reCeption (open to all): October 9 • 5 – 7 pm • Gudelsky Wall of Honor exhibit dates: October 9 – October 23 • Weinberg Atrium artwork piCk up: October 24 – 25 • 7 – 10 am & 3 – 6 pm All participants will be contacted via email with pick up locations
All UMMC employees, physicians, and their immediate family members are invited to exhibit their artwork and compete for cash prizes sponsored by the National Arts Program® in the following categories: Amateur Adult, Intermediate Adult, Professional Adult, Youth 12 & Under and Teen 13–18. There is no entry fee, but all entries must be the original work of the applicant, completed within the last three years.
For more information, visit umm.edu/arts, the intranet, or contact rachel hercenberg, Venue Coordinator, at 410-328-8893 or firstname.lastname@example.org.
Sponsored by the C2X Healing Arts Team
What’s in Store for July 2013 and Beyond Sylvia Daniels, BSN, RN, Manager, Regulatory Compliance & Outcomes
Since 2002, the Medical Center has collected, reported, and worked to improve the quality of care provided to our inpatient population. As early as July 2013, the Maryland Healthcare Commission will require all Maryland hospitals to report data for the outpatient core measure set. This measure set, developed by CMS, is intended to provide a uniform set of quality measures to be implemented in the hospital’s outpatient settings. The primary purpose of these measures is to stimulate and support a significant improvement in the quality of care for patients receiving services in the hospital outpatient settings. The focus of this measure set is the adult and pediatric emergency departments, ambulatory surgery, and services provided in the diagnostic imaging department. This measure set is composed of 3 types of measures – claims, structural, and abstraction. The claims measures are those that will use the information about an episode of care from our billing claims to determine imaging efficiency in our use of CT scans, mammography, and MRIs. The purpose of reporting these measures is to reduce unnecessary exposure to contrast materials and/or radiation, ensure adherence to evidence-based medicine and practice guidelines, and to prevent wasteful use of resources. We will begin to submit data in July 2013.
The claims measures are: OP-8 OP-9 OP-10 OP-11 OP-13 • OP-14 • OP-15 • • • • •
MRI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT – Use of Contrast Material Thorax CT – Use of Contrast Material Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low Risk Surgery Simultaneous Use of Brain CT and Sinus CT Use of Brain CT in the Emergency Department for Atraumatic Headache
The structural measures assess whether organizational resources and arrangements are in place and used to deliver high-quality health care, such as the number, type, and distribution of medical personnel, equipment, and facilities. Aggregate data for these measures are submitted once a year, beginning in July 2014. The structural measures are:
• OP-12 • OP-17 • OP-22 • OP-25 • OP-26
The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into Their Qualified/Certified EHR System as Discrete Searchable Data Tracking Clinical Results Between Visits Left Without Being Seen Safe Surgery Checklist Use Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures
A Rapid Improvement Event to Improve Vascular Outpatient Flow M. Patricia Wall, BSN, RN, CCRN, Senior Clinical Nurse II, Interventional Radiology
“A Rapid Improvement Event (RIE) To Improve Vascular Outpatient Flow Through Interventional Radiology” is the title of a poster presented on April 16, 2013 at the Association of Imaging and Radiology Nursing (AIRN) Convention held in New Orleans. An RIE, rapid improvement event, is a weeklong interdisciplinary team event where participants rapidly learn and apply lean principles to streamline processes and decrease waste. At the University of Maryland Interventional Radiology Department, inefficiencies in patient pre-procedure preparation created delays in outpatient flow across the continuum of care. This issue was made apparent by a decrease in patient satisfaction scores related to wait times for procedures. In interventional radiology (IR), we looked at increasing patient and staff satisfaction by decreasing inefficiencies in the time spent admitting patients pre-procedure. The team was made up of a dynamic variety of members ranging from a senior vice president to a patient transporter. Various members of the IR department were involved, as well as “fresh eyes” from other hospital departments.
The RIE team spent one week dedicated to identifying issues related to patient prep and flow. Out of this weeklong event came several practice changes that were implemented as rapid experiments. These included a new chart system, a pre-procedure checklist, defined expectations for referring physicians, and standard work for staff. These rapid experiments produced a more efficient and organized department. We look forward to performing additional rapid improvement events to increase our efficiency and decrease overall waste.
The abstraction measures are detailed in the table that follows. They will focus on the care of AMI, chest pain and stroke patients in the ED, ED throughput (timeliness and efficiency), pain
management for patients with long bone fractures in the ED, and outpatient surgery. Data for these measures will be abstracted from the patientsâ€™ medical records starting in January 2014.
OP-1 Median Time to Fibrinolysis
Time to fibrinolytic therapy is a strong predictor of outcome in patients with an acute myocardial infarction.
OP-2 Fibrinolytic Therapy Received within 30 Minutes of ED Arriva
Time to fibrinolytic therapy is a strong predictor of outcome in patients with an acute myocardial infarction.
OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention
The early use of primary angioplasty in patients with ST segment elevation myocardial infarction (STEMI) results in a significant reduction in mortality and morbidity.
OP-4 Aspirin at Arrival
The early use of aspirin in patients with AMI results in a significant reduction in adverse events and subsequent mortality.
OP-5 Median Time to ECG
Guidelines recommend patients presenting with chest discomfort or symptoms suggestive of STEMI have a 12-lead electrocardiogram performed within a target of 10 minutes of emergency department arrival.
OP-6 Timing of Antibiotic Prophylaxis
Multiple studies have demonstrated that timing is critical to the effectiveness of surgical antimicrobial prophylaxis. Current guidelines recommend dosing within one hour before incision.
OP-7 Prophylactic Antibiotic Selection for Surgical Patients
A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intra-operative contaminants for the operation.
OP-18 Median Time from ED Arrival to ED Departure for Discharged ED Patients
Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care.
OP-19 Transition Record with Specified Elements Received by Discharged Patients
Providing a detailed transition record at the time of ED discharge enhances the patientâ€™s preparation to self-manage post-discharge care and comply with the post-discharge treatment plan.
OP-20 Door to Diagnostic Evaluation by a Qualified Medical Personnel
Reducing the time patients remain in the ED can improve access to treatment and increase quality of care.
OP-21 Median Time to Pain Management for Long Bone Fracture
Pain management in patients with long bone fractures is undertreated in EDs. ED pain management has room for improvement.
OP-23 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 Minutes of ED Arrival
Improved access to diagnostic imaging assists clinicians in the decision-making process and treatment plans. Decreasing radiology turnaround times will enhance decision-making capabilities for patients with TIA or Acute Ischemic Stroke.
OP-24 Cardiac Rehabilitation Patient Referral from Outpatient Setting
Cardiac rehabilitation is increasingly recognized as an integral component of the continuum of care for patients with cardiovascular disease. Despite the documentation of substantial morbidity and mortality benefits, cardiac rehabilitation services are vastly underutilized. This measure offers the potential to enhance referral to, enrollment in, and completion of cardiac rehabilitation.
Nurses play a key role in impacting patient outcomes and improving the processes of care. Since the focus of the outpatient measures is timeliness and efficiency, it will be important for physician orders to be implemented in a timely manner and for documentation to reflect the accuracy and timeliness of care
provided. Nurses will directly impact such outpatient measures as patients receiving discharge instructions following an ED visit, the timely administration of pain medication and aspirin, and EKGs being done in a timely fashion for patients with chest pain.
continued from page 6.
Virginia echoed Fred’s comments and also said, “I love this unit! I love this unit! We were on 3D before and we’ve had a change in our patient population and environment. When we moved to C5E, we put a lot of initiatives in place and have seen great results. The culture of the unit is positive and our manager listens to us.” The “feel” of the culture is evident on the unit’s large C2X Bulletin Board, visible as you enter the unit. On the bottom row, where each unit can customize the information with its own content, you can find the following under the pillars: ◗◗ People: New C5E employees are pictured. ◗◗ Service: Patient satisfaction results are listed. The team is especially proud that its pain management scores have been above the 90th percentile for each quarter of the past year. After an intensive re-education about assessment of breakthrough pain, they were able to see significant improvement in the HCAHPS data. ◗◗ Safety & Quality: In The Quality Management Briefing, a System newsletter about quality, C5E is featured for its work on hand hygiene. ◗◗ Stewardship: The successful Medical-Surgical toy drive, which raised more than 300 gifts for children, is listed. ◗◗ Innovation: The Quest, a staff newsletter edited by Victoria Phelps and Katrina Daye-Whitehead, was just launched. The Quest, in its inaugural issue, encouraged the staff to get involved and described all the unit-based committees.
Vascular Surgery Progressive Care Unit Team Members
In addition to the aforementioned C2X Committee, C5E has robust committees in place for Clinical Practice, Education, and Safety & Quality. Simone Odwin-Jenkins said, “We have revamped all of our unit-based committees to make them purposeful with measurable goals.” Simone speaks with energy and focuses on excellent outcomes. She is described by the group as someone who listens well and is open to change. She said, “I tell the team what I’m thinking about and they are so creative, they can take my vision to places I hadn’t dreamed of. I like the Magnet concept, with centrally strong shared governance. A member of each of our four, big unit-based committees attends the hospital-wide corresponding committee and brings back the information and education to our whole team. The group is open,
flexible and readily embraces new ideas. Whenever we have a sense of resting on our laurels, one of the staff members inspires us to re-focus. It is a great team, environment, and culture.” What is in store for C5E? More change. They transition to intermediate care (IMC) status by November. Currently, the staff members are attending the Critical Care course and all of the nurses are becoming ACLS certified. The nurses and techs from C5E are shadowing nurses and techs in the Surgical IMC to learn from their colleagues. The team also has plans to spend time in the OR observing vascular cases so they have a thorough understanding of the continuum for their patients. Rajabrata Sarkar, MD, PhD, chief of vascular surgery, said, “The nurses on C5E have made significant progress in caring for our patients. I find the nursing staff friendly, responsive and always willing to assist when I am on the unit. We look forward to continuing our collaborative work and efforts focused on education and training with the same positive spirit.” He and Robert Crawford, MD, Maureen Shirflett, CRNP, and Kristy Gorman, MS, RN, OCN, Clinical Practice & Education Specialist offered 16 hours of classes to educate the C5E staff members about vascular surgery when they moved from 3D. Now, as C5E transitions to an IMC, we will once again count on our colleagues for further education. The nurses have also remembered to educate new staff, as part of their onboarding to the unit. Recently, Virginia just taught a follow-up vascular class to staff members who joined the unit over the past year. Susan Sims, RN, Clinical Nurse II, said, “The vascular class taught by Virginia was informative and she did a great job. I’ve been here for just a little over a year now, after my previous nursing position at another hospital for 19 years, and I’m so happy with my decision to come here. I’ve been impressed with UMMC and this wonderful unit; the nurses are great and we have a constant learning environment.” Susan has a wealth of experience in teaching cardiac care, arrhythmias, and ACLS, and in addition to caring for patients, she performs annual competency assessments in reading and interpreting EKGs for the unit. Informally, Virginia leaves weekly rhythm strips at the nurses’ station for nurses to independently assess themselves. If they would like remediation, Susan makes herself available. It is easy to encounter a positive spirit throughout C5E. Anthony Barksdale, unit secretary, greeted me with a warm C2X kind of welcome when I entered the unit. He has been on the C5E for four years. Prior to working in Patient Care Services, Anthony was in Housekeeping. Pauline Amaechi, patient care technician, just started working on the unit in March. “I like being a tech, I like the unit and I like the work,” said Pauline. Roslyn Mack, patient care tech, has been on the unit for three years. She said, “I like the staff and teamwork.” Cindy Schmigel, OTR/L, is a traveling occupational therapist. “UMMC is one of the best places I’ve ever worked. The hospital is clean, the staff have great rapport with the patients, the physicians get back to you almost immediately, and the Intranet resources are excellent. It is definitely a great place to be and really different, and much better than other places I’ve work as a staff member or traveler,” said Cindy. While rounding on the unit, I visited with a patient and his family member. The patient said “I’m retired police and a cynical person. I had reservations about having my surgery here. I need to tell you, this unit has a group of people here who care about what they do. continued on page 21.
news &views you&ummc: Welcoming New Nurses to the UMMC Family Martha Lefferts, BSN, RN, Clinical Nurse II, Neonatal Intensive Care Unit Rachel Hercenberg, BA, Project Specialist, Clinical Practice & Professional Development
At UMMC, our coworkers feel like family. The Medical Center offers a unique culture of support and encouragement, as we work together to deliver the highest level of care to our patients. There is a special bond and a unique experience that all UMMC badge-wearers share; who else gets to cheer in the hallways for a complete stranger’s cancer recovery when they hear the bell rung in the Department of Radiation Oncology, reference The Great Cookie as a landmark when giving directions to visitors, or see professional football and baseball stadiums when looking out the windows of the hospital? While we continue to create positive relationships with co-workers and colleagues, it is important that we make our newest employees feel welcome as part of the UMMC team. Turnover rates for nurses within two years of hire at the Medical Center have continued to increase in recent years, suggesting the need for a new onboarding strategy. Under the direction of Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services, a small group of nurses and Clinical Practice & Professional Development staff were commissioned to develop an “innovative and effective onboarding strategy” for new nurses as part of the FY’13 Nursing Strategic Plan.
In an effort to engage new nurses as they transition professionally to their role at the Medical Center, as well as transition socially to the city of Baltimore, a new program was formed called “you&ummc.” The “you&ummc” team, led by Martha Lefferts, BSN, RN, Clinical Nurse II, Neonatal Intensive Care Unit and Rachel Hercenberg, BA, Project Specialist, Clinical Practice & Professional Development, created a comprehensive website that both new and existing staff will find useful. This website offers a number of resources for staff that includes housing and roommates, city neighborhoods, UMMC culture and involvement, recreational activities, transportation, childcare, and much more. This reservoir of information can be useful to all members of the UMMC community. New nurses will be introduced to this website when they receive their offer letter, providing them with an early opportunity to acclimate to the Medical Center and the Baltimore community. In celebration of Nurses Week, the “you&ummc” team is proud to introduce youandummc.org, which we hope will serve our newest nurses as they transition to their instrumental role as a member of our Medical Center family.
Left to right: Derek Eckenrode, Martha Lefferts, John Volcy, Rachel Hercenberg, Cyndy Ronald, Justin Graves
Nurses Week 2013
N u r s e s t r ans fo r m i n g ca r e : Wo r k i n g to g e t h e r to e m p ow e r , i nn ovat e and l e ad Kick-off Event— Trends in Nursing Practice Conference – Ethics in Healthcare: Making the Just Decision This event featured a keynote address by a nationally recognized speaker, in addition to presentations by our own chief nursing officer and chief medical officer along with other UMMC employees. The conference was well attended and received very positive reviews. Support Staff Salute Day and Team Celebrations Unit based activities to celebrate the contributions made by nursing support staff that provide quality patient care. Nursing Excellence Awards This ceremony recognized the special achievement recipients and living excellence award selections. The award program was held in the UMSON auditorium to allow for greater attendance. The full program with the listing of all winners is located on the UMMC intranet under the nursing tab at the following address: http://intra.umm.edu/ummc/nursing/index.htm Clinical Practice Summit This two day long summit highlighted how nurses contribute to excellence in practice. Over 55 posters were received, and rounds were conducted on 17 of the posters. Submissions for “My UMMC Nurse” were on display at the summit.
Clinical Practice Summit
Candy Cart Rounding This was a special salute to night shift with candy carts visiting all patient care units between 9 p.m. and 11 p.m. Nursing Staff Breakfast A sumptuous breakfast served from 6 a.m. to 9 a.m. to the nursing staff by the leadership team. Nursing Grand Rounds Topic: Work—Life Balance 3rd Annual Community Health Fair The community health fair at Lexington Market was staffed by UMMC employees who contributed 525 total hours to provide support. It is estimated that over 1000 members of the community attended the fair that consisted of 31 tables of health related topics, along with blood pressure, BMI, and weight measurements. Coffee Bar Complimentary coffee, tea, and bagels were provided from 6:30 a.m. to 8:30 a.m. for those working on Saturday. “My UMMC Nurse Is A Hero” This was the first year for this type of recognition. Submissions were received from family members and friends of UMMC nurses to describe why “my nurse is a hero.”
Just a sampling —
“ ... Seeing the passion and love she takes every day with her to work makes me feel blessed...” “ ... When she tells me about her work ... she lights up. She glows when she talks about her patients. Your hospital is blessed to have her on staff!” “ ... He does special things for people without realizing how much the act will impact the person’s life.” “ ... Being a nurse is truly the calling God has for her. I enjoy working at her side. She is one of your top ten nurses.” “ ... My stepmom can make a difference in someone’s life in her job as an ER nurse. She is a hero by accomplishing the goal of giving many people a second chance at life.”
Journal Club: Repeated Scenario Simulation to Improve Nursing Competency Xiaobo Hu, BSN, RN, CCRN-CSC, Senior Clinical Nurse I, Cardiac Surgery Intensive Care Unit Pat Woltz, MS, RN, Director of Nursing Research
About 30 nurses were present for the March 2013 journal club that was facilitated by Xiaobo Hu, BSN, RN, CCRN-CSC, Senior Clinical Nurse I, Cardiac Surgery Intensive Care Unit, who reviewed a study by Abe, Kawahara, Yamashina, and Tsuboi (2013). The study evaluated the use of simulation training as an educational approach to develop clinical competencies in nurses that require critical thinking skills. Demands such as a rapidly aging society, advances in medical science and technology, and the focus on healthcare quality and safety have resulted in an increasing gap between traditional nursing education and the advanced critical thinking skills needed by competent critical care nurses.1 Simulation based education provides hands on experiences and allows for easy verification of learning outcomes based on nurses’ actions. The study used a quasi-experimental time-series crossover design to evaluate the effectiveness of repeated scenario simulation training among 24 Japanese nurses at the Tokyo Medical University Hospital. Study outcomes were selfassessed nurse competency and perception of teamwork and non-technical skill. All
nurses received six months of didactic training on cardiovascular critical care nursing and were divided into four groups for simulation training in four zones. Each group rotated through the four zones, where the order of the scenarios in each zone was randomly determined. In each zone, scenarios were repeated once and debriefing occurred during and after each scenario. Half the group participated in a scenario, followed by the second half of the group as the scenario was repeated. After each scenario, participants scored their own performance using a rubric. Participants also scored teamwork and nontechnical skill using the Teamwork Activity Inventory in Nursing Scale (TAINS).2 Results showed that regardless of the order in which groups, or the participants within a group, progressed through the various scenarios, all competency scores increased: 1) after the second simulation in a zone; and 2) as repetitions increased across zones. The TAINS survey showed significant improvement in three out of six subscale scores for “Job Satisfaction,” “Confidence as a Team Member,” and “Attitudes of the Superior” (all p’s <.05). The authors concluded that repeated scenario simulation enhanced individual nurses’ technical skill (competency) and somewhat improved their teamwork and non-technical skills. The authors acknowledged that small sample size, single site, and bias due to the voluntary nature of the participants were study limitations. Group discussion: ◗◗ The group agreed that this study supported previous research and simulation training among Japanese critical care nurses. Findings that
simulation improved nurses’ nontechnical skills, including job satisfaction, are of particular interest. Larger, multiinstitutional studies are recommended with a control group to compare didactic only to didactic plus simulation training. ◗◗ UMMC is a large academic institution with many staff, a relatively quick turnover, and different nurse experience levels coupled with cutting-edge technology and a complex patient case mix. Thus, staff education and clinical competency validation is an important part of practice. Simulation based education as an evidence-based practice for competency and critical thinking skill acquisition seems underutilized for nurses at UMMC. ◗◗ The implications of the study were highlighted by the introduction of Maryland Advanced Simulation Technology, Research & Innovation (MASTRI) Center’s Training & Curriculum Specialist and Clinical Educator, Sheree Chase, MSN/MBA, RN. Sheree answered questions about the use of scenariobased simulation in the MASTRI Center, which is located on the 7th floor of South Hospital building, and how to better use MASTRI Center resources for nurse competency training. 1
Abe, Y., Kawahara, C., Yamashina, A. & Tsuboi, R. (2013). Repeated scenario simulation to improve competency in critical care: A new approach for nursing education. American Journal of Critical Care, 22(1), 33-40.
Takayama, M. & Takeo, K. (2009). Structure of teamwork and relevant factors in nursing activities. Journal of Nurse Studies NCNJ, 8, 1-9.
online at http://www.umm.edu/nursing/newsletter.htm on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm
news &views Certification Corner
Becoming a Certified Medical Surgical Nurse Tonnette Branch, RN, CMSRN, Senior Clinical Nurse I, Charge Nurse, 13 East/West Medical Telemetry Unit
In July of 2012, I became a Certified Medical Surgical Nurse – and in the process, I became a better nurse. My nurse manager and senior nurses on my unit encouraged me to pursue certification. At first, I was reluctant. I had been out of school since 1993 and was very anxious about taking another major exam. After much thought and with my patients in mind, I realized that knowledge was power – the kind of power that I could use to be the best nurse I could be. So, I set
out for the task at hand. I was told about the Medical-Surgical certification, which I found to be aligned with my patient population. In October of 2011, several co-workers and I enrolled in the medical surgical consortium review course. Over the 3-day review course I kept thinking to myself, “Can I do this?” and reminding myself that the last major exam I had taken was the NCLEX 18 years ago. As I listened to the lecture, I realized how much I had forgotten, but was excited to fill my head with old and new knowledge. After completing the review course, my next step was to schedule a test date. Since I was anxious about the exam, I scheduled myself for the last possible date. I remember studying and thinking, “How am I going to pass this?” It felt like I was back in nursing school. On the day of the test I was encouraged and nervous. I froze with the first question and felt like I had forgotten everything I had studied. I answered the questions to the best of my ability. Down to the wire, 20 questions and 20 minutes before the computer was scheduled
to shut off. Once I completed question #150 and pressed the end button, I got an immediate score “Passed.” I was in disbelief, yet excited, and proud of myself for what I had accomplished. As a professional nurse, my goal is to be the best nurse I can be. I feel that being a Certified Medical-Surgical Nurse helps me to achieve that goal. To this day, I continually reference my notes and have shared study materials with my colleagues. Now as a certified nurse, I encourage my fellow RNs to pursue this as a professional goal. Eligibility for this certification through the Medical-Surgical Nursing Certification Board requires two years of nursing experience. On my unit, prior to the two year mark, nurses are encouraged and assisted to enroll in the review course. My unit has ten RNs who are certified and several in the test-taking process. For me, it is a great accomplishment, and I feel a sense of pride knowing that my patients will benefit from the knowledge I’ve gained.
Boston Marathon Nurse continued from page 1. wide range of issues. Exercise-associated collapse, hypothermia, and dilutional hyponatremia are among the ailments that we frequently see. At 2:50 p.m., I heard a blast not unlike the mock cannons that are fired every Sunday from Fort McHenry. Whispers floated through the staff in the tent. Could the sound that we heard be celebratory cannons? It was Patriots Day, after all. Shortly after, I heard another blast. I walked over to one of the physicians, who voiced the thought in the back of my head — that it could have been a bomb. Boston EMS personnel had been stationed in the respiratory care section of the tent, and all of their radios went off simultaneously. Some of them sprinted out of the tent while others stayed and frantically prepared their equipment. I knew something had to be seriously wrong. I looked over to the television and saw the blast being covered live. I immediately took out my phone to call my mom. When she picked up, I quickly told her, “I am safe. There are bombs in Boston, but I am safe.” I sent a text to my girlfriend saying, “I am safe.” After that moment, the phone traffic went dead. No one in the tent could get calls out. I discharged as many runners as I could from the tent. I told them that if they could walk, they should get out. The first victim to come into the tent was an image I would never forget: a young man was wheeled in with both of his legs amputated by the blast. He was awake and had mere strands of flesh hanging down from both of his legs. It was surreal. The patients started rushing in, filling every corner of the tent. All ages were present among the victims. It was mass pandemonium. Triage sections were set up in the tent so that the victims with more severe injuries would be transported first. A subsection of the tent was assigned as the morgue. I snapped into gear. I had the training, and now I just had to use it. I walked up to one of the victims awaiting transport. He already had tourniquets on both of his leg amputations, and the bleeding
was controlled. I started an IV and hung fluids. But what else could I do for this man? He needed surgery, and we could not do that in the tent. There were four other doctors and nurses around his stretcher, so I stepped back for a moment to collect my thoughts. Could this be real? Or was this just a horrible nightmare that I would surface from soon? A physical therapist in tears approached me. She was extremely upset that none of the runners were being treated for their injuries. I quickly eyeballed the remaining runners in the tent to make sure they had no life-threatening injuries. I then moved over to the level three section of the tent. I found an adolescent girl and her mother who each sustained injuries to both legs. The girl was panicking that she would lose her legs. I reassured her. I started caring for the girl and her mother. I put in IVs, reviewed their injuries, and splinted their legs for transport. I even started taking a blood pressure on the mother, when I soon realized that the number is meaningless in the chaos of a mass-casualty incident. About 25 minutes after the blast, we had all 97 of the blast victims who came through our tent transported to hospitals. We transferred the remaining runners to Medical Tent B. Shortly after, the police moved us out of the tent and sectioned the road off as a crime scene. I heard another bomb go off, but was reassured by another volunteer that it was a controlled detonation by Boston police. This tragedy, for me, was a major reality check. It emphasized for me the importance of family, friends, and — most importantly — LIFE. My heart goes out to the families and the victims of the Boston Marathon bombing. That said, without such a well-trained, organized and dedicated group of first responders that day, there would have been more casualties. The medical professionals in Medical Tent A, Boston EMS, Boston Police, and a countless number of bystanders saved many lives that day. I am proud to have worked among such a great group of people. I am proud to be a Boston Marathon Nurse.
Improving Pain Management – Strategies that Work Karen Snow Kaiser, PhD, RN, Clinical Practice Coordinator, Division of Quality and Safety
Consumer satisfaction ratings are used nationally as one method to stimulate healthcare quality improvements. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is one of the tools developed to support this initiative. Randomly selected discharged patients are asked to respond to standardized HCAHPS questions about their hospital experience by a nonpartisan group. Survey results are then reported nationally, so patients can compare hospitals (see Hospital Compare website www.hospitalcompare.hhs.gov). UMMC has identified a goal to perform better than the 55th percentile on the nationally reported HCAHPS pain subscale in the FY’13 annual operating plan. This goal is important because our HCAHPS pain survey items consistently show moderate to strong relationships between patients’ overall satisfaction ratings of UMMC and their likeliness to recommend UMMC to others. Performance on the HCAHPS pain subscale is also an important measure of improvement for our Magnet redesignation. For that measure, we must demonstrate higher than average performance (greater than the 50th percentile) for five out of the previous eight quarters. Currently our HCAPHS pain subscale is at 74.4%, slightly greater than the 55th percentile. However, we have only exceeded the 50th percentile, which is currently 73.8%, three times over the last eight quarters, resulting in an opportunity for improvement. To improve the HCAHPS pain subscale, we need to improve the scores on the two survey items that comprise the subscale. These items assess how often staff did all that they could to manage pain and whether or not pain was well controlled. The UMMC Pain Committee and Pain Task Force have been looking at ways to improve our performance on these measures. They identified our high-performing units (units with HCAHPS pain subscale scores higher than the 50th percentile). These units demonstrate at least two of the following characteristics. ◗◗ Pain Task Force members routinely attend meetings. ◗◗ Nursing leadership and/or a pain champion is highly engaged and ensures pain is a priority at the unit level. ◗◗ A unit level improvement group is focused on improving satisfaction, including special efforts targeted at improving pain management. A variety of activities have been used by the high-performing units to improve their HCAHPS pain satisfaction scores. Since pain is a complex interdisciplinary issue, most have deployed more than one strategy. Some of the frequently used strategies are: ◗◗ An enhanced focus on pain during hourly rounds and/or handoffs. ◗◗ Noting ‘prn’ analgesic medication administration times on patient white boards. ◗◗ Using patient huddles to modify the pain management plan for patients with high pain scores. ◗◗ Encouraging pain patient education video use. ◗◗ Advocating for patients with other health care professionals. ◗◗ Sharing HCAHPS pain data and patient reported pain experiences (HCAHPS’s Voice of the Patient or patient letters) weekly or bi-weekly.
The Medical Center’s HCAHPS data support using many of these strategies. There are several relationships between other non-pain HCAHPS survey items and the pain HCAHPS items. For example, nurses listening carefully, clear communication by nurses, courtesy and respect by nurses, patient advocacy, teamwork, and perceptions about receiving the proper care all have moderate to strong relationships to the HCAHPS pain survey items. This suggests that focusing on related survey items, many of which are part of our rounding and handoff initiatives, may also improve the HCAHPS pain items. Specifically, the following may improve the HCAHPS pain survey item scores and the management of our patient’s pain by paying special attention to the following: ◗◗ Being courteous and respectful of a patient’s reports of pain. ◗◗ Listening carefully about a patient’s pain concerns. ◗◗ Acting as a patient advocate for pain issues. ◗◗ Encouraging teamwork when developing or modifying a pain management plan. ◗◗ Clearly communicating the pain management plan to the patient. The high-performing units note that constant vigilance is required for them to continue to outperform the national scores on the HCAHPS pain items. There tends to be little variability in HCAHPS scores for those with scores in the “middle of the pack.” Small changes in scores may result in large shifts in percentile rank between quarters. We know that changes in clinical processes improvement take time to become routine, so we can be lulled into thinking that short term gains are permanent and slip back into old practices. Since hospitals are striving to improve their nationally reported HCAHPS scores, the target keeps shifting, with this year’s pain subscale 50th percentile increasing almost a full point over last year’s score. Therefore, becoming and staying a top performer requires constant attention to pain and the strategies used to improve its management. Another issue is that fluctuation in scores occurs by chance. The small amount of variability in the “middle of the pack” means that even by “doing nothing” we may appear to improve. These misleading gains are short lived and scores slip backwards. The “bouncing up and down” improvement in some quarters and declining in others can point to unstable variable clinical processes. Bouncing can lead to a false sense of security and a belief that we don’t need to address the issue. This is a reason why Magnet requires several quarters of demonstrating higher than average performance on several HCAHPS subscales. This helps delineate better performers, and those who are actively striving to improve performance. Based on the experiences of high performing units and an informal assessment of barriers to providing effective pain management, the Nursing Process Improvement Council and Pain Task Force members are working together to make pain management more visible and actionable on the units. They are leading the effort to incorporate the following into their unit activities: ◗◗ Increasing the focus on pain during hourly, shift change, and multi-disciplinary rounds. ◗◗ Incorporating the patient’s pain goal, time the last ‘prn’ analgesic was administered and/or time next dose is available into the pain care plan, the kardex, the plan of care or the white board. ◗◗ Using huddles to plan a modification of the patient’s pain management plan for patients with uncontrolled pain. ◗◗ Using the kardex, the plan of care, and end of shift reports to share “what works” for individual patients. continued on page 18.
news &views Nurse Practitioners in the Neonatal ICU… Caring For Our Smallest Patients Jennifer Fitzgerald, MS, NNP-BC, Lead NP, Neonatal Intensive Care Unit NP Team
It is often difficult to find the right words to sum up the role of the nurse practitioners in the Neonatal Intensive Care Unit (NICU). As a neonatal nurse practitioner (NNP), the population of patients we have chosen to care for is, in the world of advanced practice nursing (APN), a very narrow field. The NNP is recognized by the National Organization for Nurse Practitioner Faculties (NONPF) as an acute care nurse practitioner (ACNP) with an educational focus in caring for neonates with acute, critical, or chronic illnesses. People often think of the NICU as the “preemie nursery” when, in fact, premature infants are only a portion of the patients for whom we provide care. Although the tiniest and most prevalent of our patients are born prematurely, the NNP cares for any newborn with illnesses that impact the ability to successfully transition to life outside the womb. Our focus is to care for the infant within the dynamic of the family and encourage the tools which make parents and other family members knowledgeable and confident caregivers when their infant is stable for discharge.
The history of neonatal nurse practitioners in Maryland began at the University of Maryland Medical Center in 1979, with the employment of the State’s first NNP. Our team of neonatal nurse practitioners continues to grow and is currently a team of thirteen NNPs. Several years ago, we began a program to support RNs within our unit who were interested in becoming NNPs. In May 2013, the first two RNs from this program graduated and joined our NNP team, proudly continuing the legacy started at UMMC. As in all other areas of the Medical Center, medical advances and changing team dynamics require evaluation of the processes that impact care of the neonates in our unit. There are several areas where our NNP team impacts our NICU and the division of neonatology.
Our NNPs are involved in resident, staff, and community education. The NICU seems to be a world of its own and can be overwhelming for interns who are expected to perform upon arrival to our unit. Every month, one of our NNPs participates in orienting the incoming interns to the NICU and our unique environment. Our nursing and resident team members benefit from NICU cards that were developed as part of a multi-disciplinary team to communicate basic medical information and care guidelines. The continued production of these cards is maintained by one of our NNP team members, Pam Ansalvish, MS, NNP-BC. Several other NNP team members have participated in the development of a neonatology handbook of care to be published for the incoming July 2013 pediatric intern class. A process improvement project to improve the admission temperatures of our most premature infants has led to dramatic improvement in these infants. The maintenance of a neutral thermal environment takes a team effort and the involvement of Anita Macek, MS, NNP-BC, as an integral member of that team. One of the hardest parts of our job in the NICU is helping families cope with devastating outcomes and end of life care. Pediatric palliative care is an aspect of our job that is not always comfortable, but it is essential to ensure that we are providing compassionate care to our patients and their families. We are lucky enough to have some very special providers in the NICU who are able to compassionately and effectively work with our families. Two of our NNPs are planning to pursue a certification in palliative care during the next year and a half. Several of the Medical Center’s NNPs should be recognized in this article, however it takes the entire group working together to make the team so effective. The NNP team consists of the following members: Pam Ansalvish, MS, NNP-BC, Vikki Beltran, MS, NNP-BC, Nikki Brandon, MS, NNP-BC, Cecil Daly, MS, NNP-BC, Jenny Dukes, MS, NNP-BC, Myreda Erickson-O’Brien, MS, NNP-BC, Anita Macek, MS, NNP-BC, Krisitin McCullough, MS, NNP-BC, Linda Moses, MS, NNP-BC, Chrissy Mulford, MS, NNP-BC, Darbi Robinson, DNP, NNPBC, and Natalie Terrell, MS, NNP-BC. Additionally, there are two University of Maryland School of Nursing faculty members on staff with us, Dawn Mueller-Burke, PhD, NNP-BC and Susan Braid, DPH, NNP-BC. In addition to Darbi Robinson, DNP, NNP-BC, the liaison we have with the school of nursing gives our team leadership potential for future research opportunities. As the lead for this talented team of professionals that consistently provide compassionate, expert neonatal care, I would like to express my thanks publically for their hard work and dedication.
Nursing Governance Restructure Vascular Surgery Progressive Care Unit Restructures Committees Visitacion “Bing” Casal, BSN, RN, Senior Clinical Nurse I Noel Corpus, BSN, RN, Senior Clinical Nurse I Virginia Nganga, BSN, RN, Senior Clinical Nurse I Simone Odwin-Jenkins, MBA, BSN, RN, Nurse Manager Victoria Phelps, BSN, RN-BC, Senior Clinical Nurse I Vascular Surgery Progressive Care Unit
The Vascular Surgery Progressive Care Unit (VSPCU) staff, under the leadership of Simone Odwin-Jenkins, MBA, BSN, RN, nurse manager, are constantly looking for ways to improve patient care through employee engagement and patient satisfaction. To that end, we recently restructured all the committees into four major unit committees. 1. 2. 3. 4.
Clinical Practice Committee Quality & Safety Committee Education Committee Commitment to Excellence (C2X) Committee.
Every staff member is expected to be a member of a committee, and this includes nurses, PCTs, and unit secretaries. Prior to staff selection or voting, the senior clinical nurses on the unit campaigned and introduced their committees to the staff during our November 2012 staff meeting. The role of the senior clinical nurses was to act as facilitators on these unit committees. After the campaign, staff were given two weeks to decide which committee they wanted to join and were assigned to committees based on their choices and on the need for role balance within a committee. To make the transition more meaningful to the staff and to solicit better engagement, each staff member was asked to pick two top choices of a committee on which to serve, and/or send an e-mail to a manager. After the results were reviewed by the manager, each staff member was assigned to a specific committee and contacted by that committee’s facilitator. Each committee had a kick-off meeting and elected officers. Newly hired staff have three months to choose a committee. The following is a summary of the projects and activities implemented by each committee since January 2013.
Clinical Practice ◗◗ Complete bedside shift handoff went live on March 4, 2013. The incoming and outgoing charge nurse, bedside nurse, and PCT participate in a full shift report at the bedside and include the patient. ◗◗ A mobility task force has been created to assist in the mobilization of our patients. ◗◗ The committee is encouraging all nurses to pursue medical-surgical certification. Quality and Safety Committee ◗◗ Ensures that the unit committee’s goals align with the UMMC FY ’13 Nursing & Patient Care Services strategic priorities. ◗◗ Representatives from the group attend the monthly hospital-wide committees for falls, skin care, pain, and process improvement. ◗◗ The group is creating the quality and safety data board that displays the latest data for pressure ulcers, CLABSI, CAUTI, falls, hand hygiene, pain, and MIDAS documentation. Education Committee ◗◗ A journal club was created and is held monthly to discuss relevant articles from a reputable nursing journal. ◗◗ Bi-weekly education sessions are held every other Monday. ◗◗ A core curriculum in vascular surgery was implemented for all nurses. ◗◗ An annual EKG/telemetry competency was developed. Commitment to Excellence (C2X) Committee ◗◗ The employee recognition board has been installed. ◗◗ The C2X events board was mounted inside the staff lounge to acknowledge monthly birthdays, advertise staff events, and highlight the employee of the month. ◗◗ Currently working on strategies to improve patient satisfaction. Since the unit restructured all of the committees, the leadership team has noticed increased staff engagement in unit operations and involvement in decision making. There has been improved interaction with our medical staff colleagues and each other. We are proud of the work that has been done thus far, and we look forward to the continued success of the unit.
Pain Management continued from page 16. The Patient Education Council and the Pain Task Force are also encouraging the use of the pain related patient education videos. This strategy has improved our HCAHPS scores in the past. The videos address issues that have been shown to be patient barriers to adequate pain management. The videos help patients understand: ◗◗ Their right to pain management. ◗◗ The benefits of adequate pain management. ◗◗ The importance of pain assessment, including the use of pain scales. ◗◗ Their role in pain management (e.g., reporting analgesic side effects and uncontrolled pain). ◗◗ Different strategies available to manage pain. ◗◗ Realistic expectations.
Some of the strategies outlined above may appear to take an additional amount of nursing time. However, nurses report these strategies save time by reducing call light use and improving patients’ ability to perform their activities of daily living and adherence to treatments, such as physical therapy. These strategies also support UMMC’s patient-centered care model. Please help UMMC to obtain HCAHPS goals by joining with your unit’s Pain Task Force, the Nursing Process Improvement Council, and your Patient Education Council representatives in these initiatives to more effectively manage your patient’s pain.
news &views Spotlight on Pharmacy
A Prescription for Teamwork Nakia Eldridge, PharmD, Women’s and Children’s Pharmacy Manager Christina Cafeo, DNP, RN, Director, Medical and Surgical Nursing Jennifer Servary, MBA, Performance Improvement Leader
The Medication Process Improvement (MPI) Committee, under the leadership of Christina Cafeo, DNP, RN, Director, Medical and Surgical Nursing and Nakia Eldridge, PharmD, Women’s and Children’s Pharmacy Manager is a committee charged with addressing opportunities for improvements in the medication use process. A targeted area was missing medications – those medications that should be on the unit but cannot be located. The committee partnered with the Center for Performance Innovation to get a new perspective on this old problem. With the help of Jennifer Servary, MBA, Performance Improvement Leader, the MPI co-chairs agreed to target missing doses using a “Lean” approach. Lean is a systematic approach to problem solving that focuses on eliminating or minimizing waste in a process. For 2012, the committee reviewed and identified units with high missing-dose requests per month. The units were: Transplant IMC (Gud 8), Cardiac Surgery Intensive Care Unit (Gud 6), and Medicine Telemetry (11 East). Nursing representatives were recruited from each unit. They were Dana Rojek, BSN, RN, Clinical Nurse II and Nathan Shapiro-Shellaby, BSN, RN, Clinical Nurse II, Cardiac Surgery Intensive Care Unit; Jessica Dolim, BSN, RN, Clinical Nurse II, Transplant; and Mandy Chavez, BSN, RN, ACRN, Clinical Nurse II, 11 East. The pharmacy representatives were Mohammed Sarg, PharmD, Neelesh Vaiyda, PharmD, and Marisol De Leon, PharmD. The goal of the group was to recommend initiatives or experiments to decrease the missing dose requests in pilot areas by 50%.
First, the group sought to understand the current process and potential barriers in reaching their targets by conducting observations through shadowing. The nurses accompanied the pharmacists and were able to identify some pharmacy barriers, like distractions during the dispensing process. The pharmacists accompanied the nurses and were able to identify some nursing barriers, like multiple medication locations. Once the group understood the gaps and barriers in the current process, they were able to brainstorm methods for improvement or “experiments.” The group initially had more than ten experiments. These were prioritized to three for the first phase of the project. Experiment #1: Create flow and organization in the medication rooms.
The group used the “Six Sigma” (6S) method in each unit’s medication rooms. The 6S method is a six-step process: (1) sort; (2) set in order; (3) scrub; (4) make safe; (5) standardize; and (6) sustain. The event included the nurse manager, MPI team members, and unit staff. The group removed excess items from the medication rooms, created a specific location for the items needed, and labeled each drawer and cabinet. These changes established a clean environment and cues for visual management of the work area. Experiment #2: Decrease storage locations.
The group moved all medication storage areas to the medication room. By placing the medication storage locations in one area, the amount of searching and walking that nurses performed on a daily basis was reduced. Also, centralizing the location of all medications assists in the future phases of the project when the group attempts to identify other barriers to finding medications. Experiment #3: Reconfigure the Omnicell®
The current philosophy is to store emergent, non-scheduled, and controlled substances in the Omnicell®. The MPI group agreed that missing medication requests would decrease if the most frequently used medications were
available on the unit. For this experiment, medications with low use were removed, pars were modified, and medications with high use were added to the Omnicells® in the pilot areas. Over the last several months, the MPI team of nurses and pharmacists have brainstormed, implemented, and monitored the three experiments with the support of the MPI steering team. The steering team includes Mary Taylor, MS, RN, Director, Women’s and Children’s; Jonathan Gottlieb, MD, Senior Vice President and Chief Medical Officer; Agnes Ann Feemster, PharmD, Interim Director, Pharmacy; Barbara Brannan, PharmD, Pharmacy Safety Officer; C. Bret Elam, Pharmacy Practice Manager; and Bethany Shelbourne, PharmD. This group is committed to providing the team with the resources and support needed to achieve the goal of decreasing missing medication requests. Throughout the project, the pharmacy and nursing team members discovered a more respectful, appreciative, and trusting relationship. Each member invested time and energy to collect information from other frontline staff members and to understand the root cause of issues in both pharmacy and nursing. Both disciplines worked collaboratively to ensure an effective and efficient medication process. The bonds created during this project will stay for a long time after the project is completed and will hopefully spread beyond the three units piloted.
Improving Patient Family-Centered Care The Proof is in the Outcomes Gena Stiver Stanek, MS, RN, CNS-BC, Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center
The R Adams Cowley Shock Trauma Center (STC) Patient Family-Centered Care Council (PFCC) has been on a journey to improve patient family-centered care over the last several years. This interdisciplinary council, including family members, was chaired by the following nurses: Katherine Mulligan Vann, BS, RN, Senior Clinical Nurse II and Amira Lawrence, BS, RN, Senior Clinical Nurse I. The current chairperson is Karen Memphis, BS, RN, Senior Clinical Nurse I. Gena Stiver Stanek, MS, RN, CNS-BC, Clinical Nurse Specialist and Lynn Armstrong, BSN, RN, Nurse Manager, serve as mentors. The work of this council began in early 2009, after reviewing the evidence, brainstorming priority-improvement areas, and conducting a STC wide survey using the Institute for Patient Family-Centered Care assessment tool entitled, “Are Families Considered Visitors in our Hospital or Unit?” The survey included all staff, as well as patients and families. In addition, a brief survey was done to determine how nurses perceived expanding visitation. The data was analyzed and areas for improvements were prioritized. In order to move the culture and implement successful change, the council worked with Karen Doyle, MBA, MS, RN, NEA-BC, Vice President of Nursing and Operations, STC and Emergency Services, and the STC Coordinating Council. An allday kick-off retreat called, “Improving Patient Family-Centered Care” was conducted to provide education to staff from all nursing units, leadership, and the interdisciplinary team.
The results of the survey indicated several areas that needed our focus: 1) flexibility with individualized visitation; 2) families welcome 24/7; and 3) family opportunity to share information and feel welcome in discussions. The retreat agenda was geared to those focus areas with topics on patient family-centered care and a panel of former patients and families that provided feedback on what went well and what they would change about their patient experience. In the afternoon, the participants brainstormed about actions to be taken around the priority improvement areas. These action items were implemented in 2010 and are ongoing. The 2012 post-survey results reflected dramatic improvements in key areas, as summarized below: ◗◗ Nurses’ anxiety was reduced from 60% to 16%. ◗◗ Flexibility with individualized visiting increased from 0% to 80-90%. ◗◗ Families welcome 24/7 increased from 0% to 90%. ◗◗ Families welcome in discussions increased from 26% to 88%. ◗◗ Families able to share information increased from 8% to 92%. This group will continue their important work by focusing on implementing patient family-centered care bundles and improving communication related to the plan of care.
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After spending time with them, I will take these people to my grave with me, that’s how much they mean to me. They went beyond helping a fellow human being. I just can’t say enough.” Cheryl-Ann Daley, MS, RN, Clinical Nurse II, has been on the unit for two years. Cheryl-Ann, who previously earned a degree in criminal justice, said, “I enjoy working with everybody on the unit. The teamwork is great, the general attitude is positive, we have improved patient outcomes in hand hygiene and falls, and we’ve implemented some house-wide protocols. You want to be a part of a movement that focuses on improving patient care. We also focus on recognizing staff on the unit. We all work hard, moving together to accomplish something.” It’s true! The staff members of C5E have accomplished a lot! “It has been a joy to watch the cultural transformation on the Vascular Surgery PCU,” said Tina Cafeo, DNP, RN, Director, Medical and Surgical Nursing. “When you walk onto the unit, staff are openly friendly and engaging. They are innovative in their approach to improve patient care processes, satisfaction, and safety. The staff successfully made the transition from medical to surgical care delivery. This was no small endeavor. They continually evaluate their
progress to set goals and formulate plans to improve outcomes. This unit functions as a true professional environment. The staff engage in continuous change, hold each other accountable, own their practice and outcomes, and truly care for each other and their patients and families. I am so proud to have them as part of my team at UMMC.” It is rare to see a unit with this much energy and vibrancy, with a penchant for improving patient care and continuing their own professional development. If you had any doubt about the C5E staff members’ enthusiasm for quality improvement and nursing care, just watch the video “Hand Washing in the House Tonight.” Maybe you were fortunate enough to catch it at one of the C2X Employee Communication Forums? It was conceived of and written, directed and produced by members of C5E. In the video, it is evident how C5E staff members combine their love of singing, dancing and having fun with engaging colleagues from other units across the Medical Center to participate in this video about an important message for patient care. For these reasons, C5E has been awarded the CNO Team Award for Extraordinary Care for 2013. Please join me in congratulating them and recognizing their excellence.
Professional Advancement Model Promotions
Laura Bothe, RN *
Congratulations to the following UMMC nurses promoted in January and April 2013!
Emmylon Cui, BSN, RN
Melisha Spahr, RN, CCRN*
Monica Chiduza, MSc, RN, CCRN
Francis Grissom, BSN, RN
Mercy Ejikemeh, MPH, RN, CMSRN Surgical ICU
Senior Clinical Nurse I Kelly Powers, RN* Cardiac Prep & Recovery
Cherry Joy Rumbaoa, BSN, RN, CMSRN Weinberg 5
Meghan Taneyhill, BSN, RN, PCCN Cardiac Progressive Care
Nicole Fletcher, BSN, RN, CEN Adult Emergency
Mary Caroline Weaver, MS, RN, CCRN MICU
Catherine Dickel, RN, CNOR* Shock Trauma OR
Darlene Gray-Silver, BSN, RN Select Trauma IMC
Dominique Feldman, BSN, RN, CCRN
Lisa Petty, BSN, RN
Donna Walker, RN*
Rebecca Mary Gilmore, RN*
* Enrolled on a BSN and/or a MS program and graduation by July 1, 2015.
Domonique Banks, MS, RN Neuro ICU
Senior Clinical Nurse II Carolyn Wirth, BSN, RN, CCRN
Christa Zagol, BSN, RN, CNOR Select Trauma ICU
Jaclyn Bashmann, BSN, RN
Tracy Baca, BSN, RN, CCRN
Emily Coleen Smith, BSN, RN, CCRN Select Trauma ICU Transitional Care Unit-C8 Cardiac Prep & Recovery
Note: Next advancement application cycle is July 1–15, 2013. All applicants must have a conferred BSN or higher degree.
Shock Trauma Nurses Present Evidence-based Practice Projects Lynn Gerber Smith, MS, RN, Senior Clinical Nurse II, Trauma Resuscitation Unit Roy Ball, MS, CRNP, ACNP-BC, CCNS, Clinical Nurse Specialist, Trauma Resuscitation Unit
Karen Doyle, MBA, MS, RN, NEA-BC, Vice President of Nursing and Operations, R Adams Cowley Shock Trauma Center (STC) and Emergency Services, and newly elected President of the Society of Trauma Nurses, provided opening remarks at the Society of Trauma Nurses 16th Annual Conference in Las Vegas, NV in April 2013. The Society of Trauma Nurses is a professional nonprofit organization whose mission is to ensure optimal trauma care to all people locally, regionally, nationally, and globally through initiatives focused on trauma nurses related to prevention, education, and collaboration with other
Jennifer Motley, BSN, RN, PCCN Multitrauma IMC
Terri McMichael, BSN, RN Cheron Hawkins, BSN, RN
Johnathan Klaus, RN*
Karen Doyle, Diana Clapp and Amanda Larsen
healthcare disciplines. Shock Trauma staff and their academic efforts were well represented at the conference. In addition to the multiple presentations by STC nurses, staff from the OR, PACU, and Select Trauma were in attendance. Kathryn Von Rueden, MS, RN, FCCM, ACNS-BC, Clinical Nurse Specialist, STC and Associate Professor at the University of Maryland School of Nursing, presented, “Burnout, Compassion Fatigue, Secondary Traumatic Stress: Buzzwords or Real Deal?” and “Rapid Fire Countdown: Getting the Empathy Back: Five Things You Can Do Right Now.”
Karen McQuillan, MS, RN, CCRN, CNRN, FAAN, Clinical Nurse Specialist, STC, presented, “International Nursing Collaboration to Reduce Central-Line Acquired Blood Stream Infections.” This international collaboration between Shock Trauma and Jai Prakash Narayan Apex Trauma Center in New Delhi, India focused on evidence-based best practices for the reduction of catheter-related blood stream infections. Karen received the award for best overall abstract for her poster and oral presentation. continued on page 23.
Karen McQuillan continued on page 0.
The Past, Present, and Future of Trauma Nursing Lynn Gerber Smith, MS, RN, Senior Clinical Nurse II, Trauma Resuscitation Unit
The R Adams Cowley Shock Trauma Center remains a very popular area of interest for student nurses. In particular, the Trauma Resuscitation Unit (TRU) receives an extremely high volume of requests for tours and observations. Working with Cyndy Ronald, BA, Clinical Practice and Professional Development, Manager, University of Maryland School of Nursing (UMSON) Partnership Program, Suzanne Sherwood, MS, RN, Clinical Nurse II, TRU and Assistant Professor, UMSON, and Lynn Gerber Smith, MS, RN, Senior Clinical Nurse II, TRU, presented a lecture on the history of trauma nursing to a group of more than 40 student nurses.
Sherwood and Smith are nationally recognized speakers on a variety of trauma related topics. Sherwood, who has a fascination with the history of trauma care, presented a case study on the medical and nursing care of General Stonewall Jackson, who sustained his injuries during the American Civil War. As part of the TRU staff, Sherwood and Smith work with the Air Force C-STARS in the training and education of Air Force personnel. The presentation also included advanced technologies used in today’s civilian and military trauma care. The closing case study focused on the passion that Sherwood and Smith mutually share for treatment and care of trauma patients. One student who attended the presentation commented, “Listening to Sherwood and Smith was like listening to one presenter – they could finish each others sentences.” Following the presentation, the participants were given a tour of the trauma center, which included the helipad, TRU,
Lynn Gerber Smith and student nurses
hyperbaric chamber, and various trauma inpatient units. Since the presentation and tour were well received, the content will be offered at the UMSON on an annual basis.
Shock Trauma Nurses continued from page 22. For the second consecutive year, the Trauma Resuscitation Unit (TRU) nursing staff had a poster accepted at this annual conference. Staff nurses Diana Clapp, BSN, RN, CCRN, CEN, NREMT-P, Senior Clinical Nurse II, and Amanda Larsen, AS, RN, Clinical Nurse II, were selected to present their poster, “Improving Efficiency in Trauma Patients.” Additionally, Clapp and Larsen were one of four poster presenters selected by the abstract review committee as oral abstract winners for evidenced-based practice. Working with Deborah Stein, MD, MPH, FACS, FCCM, Associate Professor of Surgery, Medical Director, Neurotrauma Critical Care, Chief, Section of Trauma Critical Care, Department of Surgery and Kristin Seidl, PhD, RN, Director of Quality and Patient Safety Officer, Clapp and Larsen conducted a retrospective review of radiation exposure, repeat radiology testing, and staff satisfaction in patients transferred to STC prior to and after implementation of a radiographic image importation process. This process allows radiographic studies, like CT and
X-rays, performed at other hospitals to be imported to the radiology system at STC. Clapp and Larsen noted that after implementation, patients underwent fewer repeat radiographic studies, were exposed to less radiation, and practitioner satisfaction increased, as they were able to immediately review films and formulate a plan of care. Note: Clapp and Larsen wish to acknowledge the assistance of Roy Ball, MS, CRNP, ACNP-BC, CCNS, Clinical Nurse Specialist, TRU and Ellen Plummer, DL, MJ, MSN, MBA, RN, CCRN, Senior Clinical Nurse II, TRU with this project. The Shock Trauma Acute staff was also well represented at the meeting and shared their poster, “Hourly Rounding on an Acute Care Trauma Unit.” Katherine Mulligan Vann, BSN, RN, Senior Clinical Nurse II and Shanna Hartman, BSN, RN, Senior Clinical Nurse II, presented their patient and staff satisfaction scores before and after implementation of hourly rounding. Since implementation of hourly rounding, patients’ perceptions of teamwork, safety, call bell responsiveness, and overall staff responsiveness have all
improved and now exceed the national benchmarks. In addition, their already low fall rate has decreased by 50%, significantly below the national benchmark. Other authors of the poster included Shock Trauma Acute staff members Allison Payne, BSN, RN, Senior Clinical Nurse I, Mark Bauman, MS, RN, CCRN, Nurse Manager, and Gena Stanek, MS, RN, CNS-BC, Clinical Nurse Specialist.
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Clinical Practice Update Pressure Ulcer Documentation Clinical Intake/Triage Practice Update : PressureForm Ulcer Documentation Changes in Electronic & Changes in Electronic Intake/Triage Form & Aranz Camera Rollout Aranz Camera Rollout What is the Aranz Wound Mangement System? It is a UMMS initiative for standardized wound documentation across the continuum. A major component of the Aranz system is a camera that will image and measure wounds, as well as interface with the clinical information system. Details and Benefits of Using the System Who: The Wound Ostomy Continence Nurse (WOCN) team will pilot the Aranz camera only on patients admitted with pressure ulcers and patients who develop a hospital acquired pressure ulcer. Where : CS ICU, MICU, SICU, and Multi Trauma ICU. When: April 29 to May 31, 2013 then expect to see expanded locations. Why? The camera & enhanced documentation will assist us in identifying the size and location of any pressure ulcers present on admission so that we can avoid them being categorized as hospital-acquired. The wound location must be specifically documented to match the picture taken with the Aranz camera.
Wound/Ostomy/Continence R isks section of the Intake and Triage form. If the presence of Pressure Sores (Highlighted Blue) is selected, the Wound Documentation section generates and displays for the user to complete.
Contact: Please contact a member of the WOCN team at ext. 8-6448 for more information
The nurse will document the presence of pressure ulcers in the locations noted in the screen shot. When complete, select the blue circular arrow to return to the intake/triage form.