News and views summer 2013
News & Views is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center.
news views Summer 2013 A Publication of the Department of Nursing and Patient Care Services University of Maryland Medical Center Implementation of the Pediatric Early Warning Score (PEWS) at UMMC Diana Novak, MS, RN, CCRN, Pediatric ICU, Lisa Sliva, BSN , RN, CPN, Acute Care Pediatrics and Jessica Strohm-Farber, DNP, CRNP, Pediatric ICU A code-blue event on the pediatric acute care unit is a rare occurrence, but when it happens, the stakes are high. Such events outside of the intensive care unit are uncommon, but all hospitalized pediatric patients are at risk for sudden deterioration. The chances of survival after pediatric cardiac arrest are poor, with survival rates reported between 15 to 36%.1 Rapid response teams (RRT) and early warning scores (EWS) are two systems that can potentially improve these outcomes. While RRTs effectively bring critical care experience to the patient’s bedside, the teams are often called too late.2 The use of the Pediatric Early Warning Score (PEWS) can provide the earlier identification and intervention needed to improve patient outcomes. PEWS is an objective scoring tool based on the patient’s behavior, cardiovascular status, and respiratory status.3 The tool helps to “package” the patient’s physiological data and clearly identifies the patient’s deteriorating status. The “packaging” effect of early warning scores empowers nurses with one study reporting an 80% increase in nursing confidence.4 Pediatric Nursing Team Implements PEWS on Acute Care Unit Early warning scores, such as PEWS, also improve communication between members of the care team, providing a concise, objective, and standardized means of communicating concern about a patient. Improved communication is significant to patient outcomes since communication failure is the root cause of more than 60% of sentinel events reported to The Joint Commission.5, 6, 7 PEWS has been shown to identify patients with at least an hour’s warning prior to a code-blue event. One study demonstrated greater than 11 hours forewarning time.8, 9, 10 The situational awareness created by using PEWS reduces unrecognized deterioration of patients, allowing for earlier identification of deterioration, escalation to a higher level of care, and earlier intervention, ultimately leading to improvement in patient outcomes.11 In February of this year, an interdisciplinary workgroup was created by UMMC pediatric providers in order to implement PEWS within the University of Maryland Children’s Hospital. The goal of PEWS implementation is to identify the potential for patient deterioration; with the objective of early identification of evolving critical illness and reduction of code-blue events within the pediatric population. Prior to the initiation of the workgroup, a PEWS feasibility study was completed to determine the appropriateness of PEWS for the UMMC inpatient pediatric population and to determine PEWS thresholds for the continued on page 4. Lisa Rowen’s Rounds: Becoming a High Reliability Organization Whether we travel in an airplane, ride on a roller coaster or live near a nuclear reactor site, we expect the experience will be safe and consistently reliable. If you were told your air travel or roller coaster ride would be safe 90% of the time, how would you feel? Would that be good enough? How would you feel Lisa Rowen, DNSc, RN, FAAN, if a nuclear reactor site within miles of your home Senior Vice President and announced its safety system could be counted on Chief Nursing Officer, Nursing and Patient Care Services 93% of the time? Would you be impressed? I’m going to guess that no, you would not be impressed. In fact, if I were told these statistics, I’d opt not to ride an airplane or a roller coaster, and I would not buy a home near the nuclear reactor site. These odds are just not good enough. Every time a patient enters a hospital, he or she expects the experience to be safe and highly reliable. Patients expect their lab work and diagnostic testing to be performed correctly and assessed in a timely and accurate manner. They assume they will receive the correct care or procedure ordered by their provider. They believe the blood products and medications continued on page 16. 2 Summer 2013 In This Issue Implementation of PEWS at UMMC Lisa Rowen’s Rounds 1 Corporate Compliance 2 Utilizing the Culture of Safety 3 Nursing Grand Rounds 7 8 EPIC Validation Process Reviewed 9 Core Measures 10 Collaborative Nursing Practice with Korean Students 12 2013 Student Nurse Residency Program 14 Journal Club Hot Topics 15 Staff Publications & Presentations 17 Spotlight on Pharmacy 20 Honorable Mention 21 Certification Corner 24 Clinical Practice Update 1 Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer Toya Jackson, Director of Compliance In each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) for News & Views. We are looking for new ways to reach out to employees to raise awareness of compliance issues. Please let us know what you think, or suggest topics by emailing email@example.com or firstname.lastname@example.org. Compliance FAQ Q: I am a full-time medical center employee and I am currently serving on a Nurse Advisory Board for a pharmaceutical company. Is this a conflict of interest? A: Our policy does not prohibit there being a relationship. However, we would recommend that you obtain approval from your manager and vice president, as well as Human Resources. As a UMMC employee, you would be expected to use your personal time when serving as a Nurse Advisory Board member. For additional information, please refer to the Disclosure of Financial Relationships (i.e. conflict of interest) and Vendor Relationships policies, which are available on the UMMC Intranet under Policy & Procedure - Administrative policies. Find News&Views online at http://www.umm.edu/nursing/newsletter.htm and on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm Editor Allison Murter, MSN, RN Lead 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 Carolyn Guinn, MSN, RN Magnet Program Director Anne Haddad Publications Editor, University of Maryland Medical System Suzanne Leiter Executive Assistant to the Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services Chris Lindsley Director, Communication 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 Fall 2013 Winter 2014 Spring 2014 Summer 2014 Due Date October 7, 2013 January 6, 2014 May 12, 2014 July 7, 2014 Displaying Credentials 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 Utilizing the Culture of Safety to Enhance Process Improvement Jacqueline Rodriguez, BSN, RN, Senior Quality and Compliance Coordinator The landscape of health care is quickly changing in the ambulatory arena due to new regulations and the anticipated growth of commercially insured patients. These changes are driven by the implementation of the Patient Protection and Affordable Care Act and the utilization of electronic medical records (EMR) such as Portfolio, the Medical Center’s EMR, sometimes called by the name of the software company, EPIC, that adapted it for the University of Maryland Medical System. As we embark on new processes to address these changes, it is vital that we develop workflows that are highly reliable. Ambulatory Services is using the principles of a High Reliability Organization (HRO) and elements of the LEAN process improvement methodology to address systematic process failures during this transition period. Our journey began with leveraging the RL 6 (UMMC incident reporting system) to promote a culture of safety. This is a key component in identifying systematic failures as processes change. Ambulatory took the approach of viewing the RL 6 reporting database not only as an adverse event capture system, but also as a safety monitoring system, by emphasizing near misses and minor patient issues that are not adverse events to be reported. Multiple training sessions were held to prepare front-line staff to increase reporting into the system and to promote a blame-free environment when entering safety issues. Leadership then was able to see trends more clearly. The lab ordering process was identified as a significant area of risk for our ambulatory clinics. One trend indicated that the outpatient labs were being processed at the incorrect resulting lab agency. Labs are directed to resulting agencies based on insurance, and each lab-resulting agency has different requirements for processing specimens, such as ordering test codes and preparing samples. The requisition serves as the medical order and needs to be complete and accurate according to the requirements of each lab-resulting agency. A rapid improvement event was developed for the University Health Center- Medicine Service clinic (UHC) and the lab-resulting agencies used to process labs (the UMMC hospital lab and LABCORP). The awareness of the insurance driven lab resulting agency process and EPIC’s nuances for addressing resulting lab agencies were new to the Staff at UHC. The staff was unaware of the need to select a resulting agency when ordering the lab test, and would leave the agency and code sections of the requisition blank. This was known as a generic requisition. Errors that occurred due to utilizing a generic requisition included an increase in canceled /incorrect test results due to wrong specimen preparation, increased cost to patient, increased burden to the clinic staff due to increased calls from the resulting agency questioning the orders, and results sent to the wrong physician. Increased Managed Care Organization (MCO) enrollment and changing insurance rules increased the volume of errors when using a Generic lab requisition. The current workflow was evaluated and interventions planned utilizing LEAN methodology and tools that emphasized detailed process mapping, gap analysis and a solutions approach. Workgroups were formed, consisting of personnel from registration, ambulatory services operations, physicians, nurses, lab personnel and EPIC support. The workgroups were facilitated by Ambulatory QI in conjunction with a certified LEAN facilitator. Karen Lyons, BSN, RN, CCHP, Nurse Manager of UHC, stated “The systematic approach used to address the lab requisition issues we were having proved invaluable. Through a series of blame-free multi-disciplinary meetings, root causes were identified; action plans developed and the plans were implemented successfully to the satisfaction of all involved”. Solutions suggested by the workgroup and implemented Task the registration staff to validate insurance and indicate associated lab-resulting agency Educate clinicians on EPIC lab ordering features and the ramifications later in the process that can occur due to use of generic forms Expand check-out process to include review of lab requisitions and to send back generic requisitions to the ordering physician Lab registrar is to ensure that the insurance is attached and to report to the clinic any inconsistency noted between labresulting agency and insurance. Encourage communication between lab personnel and clinics if Generic requisitions were submitted. Analysis of the data revealed a significant decrease of generic requisitions along with a decrease of 74% of lab-related issues (mishandled/wrong tests performed and lost results) after implementation. The strategies for improvement are slated to be rolled out to all clinic settings. Increased RL 6 reporting through the promotion of a safety culture resulted in valuable data that assisted the improvement process. Identifying systematic failures should be addressed using HRO principles such as awareness of potential failure junctions, sensitivity to operational workflows of all departments and health care partners, not oversimplifying solutions to problems, utilizing the expertise of all staff personnel, and building resilience into processes by using redundant checkpoints for anticipation potential failure points. When using HRO principles coupled with strong process improvement methodologies such as LEAN, ambulatory staff and leadership will be best positioned to handle the quickly changing landscape of our health care delivery system. 3 4 Summer 2013 Pediatric Early Warning Score, continued from page 1. UMMC PEWS Algorithm Patient assessed by RN and PEWS score assigned PEWS Score 0-2 PEWS score 3 total for all categories Reassess and rescore PEWS every 4 hours Patient on 5 A, B, C Patient on 5D Notify PAO to evaluate within 10 minutes (first time score is 3 or with any change in component of score). Reassess and rescore PEWS every 4 hours Notify charge nurse & RT for awareness (first time score is 3 or with any change in component of score). Consider CR monitoring. Reassess and rescore PEWS every 2 hours x 2. Follow algorithm. If PEWS remains the same for same criteria or is improved, may resume PEWS every 4 hours and notify PAO for increased score (score of 3 in one category or score of 4 or greater). 1. If at any time you are concerned that a patient is worsening or in need of escalation of care and you are unsuccessful in contacting the PAO (5 A, B, C patients) or PICU NP/fellow/attending (5D patients) within 10 minutes, activate the pediatric rapid response team. 2. For transfers to a lower level of care, patients with a PEWS score of >3 requires evaluation by a PICU attending, fellow, or NP prior to transfer. development of a rapid-response algorithm. This data served as the basis for PEWS implementation within the UM Children’s Hospital. Subsequently, an interdisciplinary workgroup of physicians, nurses, and respiratory therapists was created to facilitate implementation of PEWS. The workgroup was divided into five subgroups, with the goals of adapting a standardized PEWS measurement tool and algorithm to UMMC’s pediatric patient population, educating staff regarding PEWS and its implementation, performing a trial period where gaps or redundancies could be assessed and/or modified, and performing ongoing monitoring of PEWS after implementation. On July 1, 2013, in as few as four months, these goals were accomplished by providing education and awareness in various forms, including 1:1 nursing and ancillary staff education, town-hall meetings, physician-to-physician meetings at the attending and resident levels, and divisional staff meetings among respiratory therapists. A standardized algorithm and scorecard were developed by the workgroup and subsequently revised as a result of a three-week trial period. They are currently in use on both the Acute Care Pediatrics Unit and the Pediatric Intermediate Care Unit, where patients are assessed by a registered nurse and assigned a PEWS score at routine intervals. The scorecard provides a systematic way to categorize and “package” a patient’s status in the form of a “score” based on patient assessment and vital signs. A set of vital signs parameters was adapted for use and is located with the scorecard in each of the patient bedside charts. In addition, an associated PEWS algorithm news &views for all non-ICU level patients on 5A, 5B, 5C, 5D PEWS score 3 in one category or > 4 total Patients on 5 A, B, C Patient on 5D Activate pediatric rapid response team and notify charge nurse. Implement CR monitoring. Contact PICU attending, fellow, or NP for evaluation and rescore PEWS every 2 hours x 2. Follow algorithm. If transfer to 5D is not indicated: • Continue CR monitoring then reassess and rescore PEWS every 1 hour x 2. If score is not improved • Notify PAO • Notify PICU attending, fellow, or NP as appropriate for re-evaluation. If score is improved, rescore per algorithm. If PEWS remains the same for same criteria or is improved, may resume PEWS every 4 hours and notify PICU attending, fellow, or NP for increased score. PEWS score > 5 for patients on 5D Contact PICU attending, fellow, or NP for evaluation within 10 minutes and PICU charge nurse. If transfer to PICU care is not indicated, rescore PEWS every 2 hours x 2. Follow algorithm. If PEWS remains the same for same criteria or is improved, may resume PEWS every 4 hours and notify PICU attending, fellow, or NP for increased score. PAO to determine need for continued CR monitoring. Revised 6/10/13 3. When a clear attributable cause for a high PEWS score can be identified such as tachycardia for asthmatic on nebs or low resting heart rate for an athletic adolescent, the PAO (5 A, B, C patients) or PICU NP/fellow/attending (5D patients) may be called instead of a rapid response as appropriate based on clinical judgment. guides the frequency of PEWS scores and includes thresholds for physician evaluation and mobilization of the pediatric rapid response team, as appropriate. Outcomes are being monitored closely, including rates for code blue and for activation of the pediatric rapid response team, in addition to critical interventions after unplanned transfer to the PICU. It is the hope of this workgroup that PEWS will eventually be implemented in all pediatric areas as another integral part of effective handoff communication between units and among all members of the health care team. The entire PEWS workgroup looks forward to sharing institutional data and outcomes for this important patient continued on page 6. safety initiative. 5 6 Summer 2013 Pediatric Early Warning Score, continued from page 5. UMMC PEWS Scorecard 0 1 2 3 Behavior • Playing • Alert • Appropriate • At baseline • Sleeping OR • Fussy but consolable • Irritable or Inconsolable • Lethargic OR • Confused OR • Reduced response to pain Cardiovascular • Pink • CRT 1-2 seconds • Pale OR • CRT 3 seconds • Grey OR • CRT 4 seconds OR • Tachycardia 20 above normal rate • Grey OR • Mottled OR • CRT >5 sec OR • Tachycardia 30 above normal rate OR heart rate below normal parameters Respiratory • Within normal parameters • >10 above normal • No retractions parameters OR • Use accessory muscles OR • Nasal flaring OR • >30% FIO2 OR • 3+ LPM Oxygen • >20 above normal parameters OR • Retractions OR • >40% FIO2 OR • 6 + LPM Oxygen • 5 below normal parameters with retractions OR • Grunting OR • 50% FIO2 OR • 8+ LPM oxygen Extra Points Q2 or more frequent interventions: • Suctioning (natural airway – not trach) OR • position changes to maintain airway OR • escalation in oxygen OR • persistent emesis Green = 0-2 Red = 3 in one category or > _4 Yellow = 3 in all categories Normal Parameters• Abnormal Awake Heart Rate (beats/min) Sleeping Heart Rate (beats/min) Respiratory Rate at Rest (breaths/min) Blood Pressure Systolic Blood Pressure Diastolic Newborn up to 1 month 100-205 90-160 Infant (1-12 months) 100-180 90-160 Toddler (13 months – 3 years) 98-140 80-120 Systolic Hypotension 40-60 67-84 35-53 <60 30-53 72-104 37-56 <70 22-37 86-106 42-63 <70 + (2x age in years) Preschool (4-6 years) 80-120 65-100 20-28 89-112 46-72 School Age (7-12 years) 75-118 58-90 18-26 97-120 57-80 For children between 1-10 years of age Adolescent (13-19 years) 60-100 50-90 12-20 110-131 64-83 <90 (10 years and older) *Hazinski, M.F. (2013). Nursing care of the critically ill child (3rd ed.). St. Louis, MO: Elsevier Mosby. *Hockenberry, M.J., Wilsom, D., & Winkelstein, M.L. (2005). Wong’s essentials of pediatric nursing (7th ed.). St. Louis, MO: Elsevier Mosby. References: 1 Tucker, K., Brewer, T., Baker, R., Demeritt, B., & Vossmeyer, M. (2009). Prospective evaluation of a pediatric inpatient early warning scoring system. Journal for Specialists in Pediatric Nursing, 14(2), 79-85. Revised 6/10/13 7 The Joint Commission. (2007). Improving America’s hospitals: The Joint Commission’s Annual Report on Quality and Safety. Retrieved from http://www.jointcommission.org/ assets/1/6/2007_Annual_Report.pdf 2 Cole, J. (2012). On the frontier of pediatric nursing in a community hospital implementing Pediatric Early Warning Score (PEWS) [PowerPoint slides]. Retrieved from https://pedsnurses.org/conferences/conf11/handouts/C2.pptx 8 Akre, M., Finkelstein, M., Erickson, M., Liu, M., Vanderbilt, L., & Billman, G. (2010). Sensitivity of the Pediatric Early Warning Score to identify patient deterioration. Pediatrics, 125(4), 763-769. 3 Andrews, T. & Waterman, H. (2005). Packaging: a grounded theory of how to report physiological deterioration effectively. Journal of Advanced Nursing, 52(5Z), 473-81. 9 4 Skaletzky, S., Raszynski, A., & Totapally, B. (2012). Validation of a modified Pediatric Early Warning System Score. Clinical Pediatrics, 51(5), 431-435. Duncan, H., Hutchison, J., & Parshuram, C. (2006). The pediatric early warning system score: A severity of illness score to predict urgent medical need in hospitalized children. Journal of Critcial Care, 21(3), 271-278. 10 Parshuram, C., Hutchison, J. & Middaugh, K. (2009). Development and initial validation of the bedside Paediatric Early Warning System Score. Critical Care, 13(4), R135. 11 Brady, P., Muething, S., Kotagal, U., Ashby, M., Gallagher, R., Hall, D.,…Wheeler, D. (2013). Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics, 131(1), 298-308. 5 6 Andrews, T. & Waterman, H. (2005). Packaging: a grounded theory of how to report physiological deterioration effectively. Journal of Advanced Nursing, 52(5Z), 473-81. Cole, J. (2012). On the frontier of pediatric nursing in a community hospital implementing Pediatric Early Warning Score (PEWS) [PowerPoint slides]. Retrieved from https://pedsnurses.org/conferences/conf11/handouts/C2.pptx news &views Nursing Grand Rounds: The Future of Health Care Delivery By Nelia Zhuravel, BS, Project Specialist, Clinical Practice and Professional Development and Patricia Woltz, MS, RN, Director, Nursing Research More than 140 attendees were present for Nursing Grand Rounds on June 19, 2013, when Carmela Coyle, President and CEO of the Maryland Hospital Association, spoke about the future of health care delivery. Ms. Coyle presented insights into the relationship between the Medicare Waiver in Maryland and the Affordable Care Act (ACA), and their impact on health care in Maryland. As the only state in the country with a federal waiver from Medicare, Maryland’s hospital reimbursement rates are set by the Health Services Cost Review Commission (HSCRC). Coyle skillfully explained how the Maryland Waiver — once a well-intended mechanism devised to keep hospital services affordable, provide access to hospital care for those without insurance, and provide accountability for hospital performance to the public and state government — is negatively affecting Maryland hospital revenues. Because the waiver is not limited to Medicare patients but affects all patient rates, Maryland hospitals have been hit particularly hard by recent changes in the ACA, compared to other states. Yet, she argued, it’s likely because of the Maryland Waiver that our state is uniquely positioned going forward to successfully implement accountable care. Coyle began by defining “Accountable Care” as integrated, value-based, data-driven, and patient-centered care that focuses on care coordination, better use of treatments, prevention and wellness, and health care provider responsibility and accountability. Integration of hospital care delivery requires stakeholder collaboration and involves payors, post-acute care providers, specialty physicians, primary care physicians, and other acute care hospitals. Using national survey data, Ms. Coyle showed that substantial gaps exist in stakeholders’ perceptions about care integration by state. Within the next five years, 83% of Maryland stakeholders expect that integration will be necessary between hospitals and primary care physicians, compared to 54% of non-Maryland stakeholders. Forty four percent of Maryland stakeholders report having made a significant investment in population health management capabilities and only 7% report that they plan to wait prior to investing, compared to 7% and 49%, respectively, of stakeholders from other states. Forty percent of Maryland stakeholders see an extreme dependency between cost reduction and quality of care, compared to only 22% of those from other states. Some attendees were surprised to learn that among health care organizations outside of Maryland, 43% do not measure the cost of adverse events, 38% do not measure the impact of readmissions, and 50% do not measure the cost of waste in care processes, such as performing unnecessary tests and procedures. These same figures of business intelligence are 9%, 7% and 20%, respectively, among Maryland health care organizations. While Maryland health care stakeholders may appear forwardthinking in terms of accountable care, Coyle pointed out that we have much room to grow. She encouraged that we stay focused on quality care, embrace a culture of teamwork, build strong relationships with each other, offer resources and education to patients, and enable ourselves to manage financial risk. Moreover, all should recognize their role and take part. Coyle stressed that accountability must be “baked in” to governance, executives, physicians, incentive and reward systems, measurement, infrastructure, and experiences. Improving health care will be achieved slowly and strategically. Providing an analogy of “one foot on the dock; one foot on the boat,” Coyle explained that we should not expect that one can simply jump in one direction or the other. Careful planning, strong leadership, and new metrics for thinking and evaluating performance are needed to make wise choices and move forward. The Accountable Care Act has adopted the focus of “The Triple Aim” initiative of the Institute of Healthcare Improvement which includes improving the experience of care, improving the health of populations, and reducing per capita costs of care. The new metrics of The Triple Aim involve capital spending, staff utilization, demand for care, financial performance, and hospital management and governance. Leadership has great responsibility to assess the organization’s current versus desired state, prioritize development, institute proven practices to develop necessary capabilities, and develop a process to measure the progress of the organization. As the current rate-setting system in Maryland is under re-negotiation, Ms. Coyle advises that we should start thinking of health care differently. She closed by emphasizing the unique and central role of health care providers in this changing environment, because “the work that you do is work that no one else can do, caring for patients and making miracles every single day!” Coyle has generously agreed to share the slides from her presentation. They can found on the Intranet at: http://intra.umm.edu/ummc/grounds/docs/ngr-presentations-june-19-13.pdf. Find News&Views online at http://www.umm.edu/nursing/newsletter.htm UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm 7 8 Summer 2013 The EPIC Validation Process Reviewed By Kathi Bishop, MS, BSN, RN, Clinical Informatics and Diane Constantine, BSN, RN, CPN, Clinical Informatics The adoption of Portfolio/EPIC as the electronic medical record (EMR) platform at University of Maryland Medical System (UMMS) has given rise to new nomenclature in our culture. In a recent article we reviewed the phase of discovery and what this means. Over the past few months, clinicians and other experts have been engaged in Step 3 of the system build, which is aptly named validation. In this article we will review the meaning of validation and the steps taken so far in the process of a systemwide EMR build. Feedback from participants and an explanation of the process is included. The validation project phase is a complex series of meetings that engage key stakeholders in the development/build of the EMR. This project is clinically driven, gathering front-line staff input to authenticate and confirm specific clinical and business workflows. This validation and input from experts is integral to a successful cross-hospital EMR build that supports and enhances our clinical operations. The validation sessions have been scheduled every two weeks throughout the summer, with clinical informatics staff inviting participants identified as key stakeholders in each workflow review. EPIC validation sessions started on June 6, 2013. The clinical informatics group disseminated large volumes of information to Medical Center leadership three weeks prior to the sessions. After significant preparation for the first week of the validation process, the medical center hosted the validation sessions. The sessions included four hospitals in UMMS. Hospitals represented included: UMMC Midtown Campus, Baltimore Washington Medical Center, University of Maryland St. Joseph Medical Center, University of Maryland Rehabilitation & Orthopaedic Institute and UMMC. The first phase of validation sessions allowed participants to review and confirm or deny workflows presented by the Portfolio/EPIC team. The workflows were based on response to feedback from the hospitals in the Medical System. Session topics included patient registration, dietary, physician rounding, billing, and nursing admission assessment. Each session centered around a list of specific validation points, representing decisions on how EPIC’s software should be tailored to a particular work process. Following a demonstration of the functionality of the system and intense discussion, the subject matter experts (SMEs) were asked to vote on each point. One spokesperson or foreman was designated for each hospital for each session. This foreman, with the support of the Department of Clinical Informatics staff, was responsible for gaining a consensus of opinions from their organization. On behalf of the designated foreman, Clinical Informatics staff entered validation decisions in Quickbase, an online database management system. All workflow decision points validated by front-line staff throughout this phase are reviewed by EPIC analysts and project staff and impact the EMR build. During validation sessions, many topics outside of the specific workflow discussed were captured by the project team for further exploration and discussion with stakeholders prior to the EMR build. Information gained from the first two validation sessions, which had 110 individual meetings with 1500 attendees, approximately 1000 from UMMC alone, has been used to develop a clear plan to determine the next steps in EPIC implementation. In validation sessions 3a and 3b, work was completed on topics discussed in the first validation meetings with further information gathering on specialty areas. As Physician Lead of the Portfolio EPIC Inpatient Implementation Project, Mangla Gulati, MD, FACP, FHM, commented, “It is a great collaborative experience. It is impressive that all hospitals, which include the five central Maryland systems, are engaged, enthusiastic, and willing to embrace change.” The end product will be the result of intense collaboration between end users and the technical team. The work of end users in these cross-hospital sessions will support the development of an EMR that will help fulfill federal mandates for meaningful use, improve compliance, improve reporting on quality indicators such as CAUTI, CLABSI, pneumonia treatment, and STEMI, and help to support the work and efficiency of front-line staff. Maryland Stroke Conference November 8, 2013 Doordan Health Sciences Institute Anne Arundel Medical Center, Annapolis, MD Register at http://ummcstroke2013-es2.eventbrite.com/?rank=3 news &views Core Measures The Medical Center Wins the 2013 Delmarva Foundation Excellence Award for Quality Improvement Sylvia Daniels, BSN, RN, Manager, Regulatory Compliance & Outcomes The Delmarva Foundation, Medicare’s Quality Improvement Organization (QIO) for Maryland and the District of Columbia, is an organization that facilitates the improvement of health services and programs provided to the people of Maryland and the District of Columbia. The foundation accomplishes this by working with patients, families, hospitals, nursing homes, academic medical centers and other stakeholders to improve health quality, efficiency, and value. To recognize health care organizations that excel in patient safety and quality improvement, the Excellence Award program was instituted. This award recognizes excellence in four national inpatient clinical areas – Acute Myocardial Infarction, Heart Failure, Surgical Care Improvement, and Pneumonia. A hospital has the opportunity of placing in one of four award categories: Honorable Mention, Quality Improvement Bronze Award, Quality Improvement Silver Award or The Delmarva Foundation Excellence Award for Quality Improvement. Where an organization places depends on the aggregate score for the 14 measures in the four core measure sets. The Excellence Award (which the Medical Center won) is the top award. This means we achieved an aggregate score of greater than 96% for the four core measure sets of SCIP, Pneumonia, AMI, and Heart Failure. Our aggregate score was 97.6%. (See Table 1). Individual Core Measure SCIP Pneumonia AMI Heart Failure Aggregate Score Score 97.1% 99.2% 99.6% 99.8% 97.6% Table 1 UMMC Individual Scores on Core Measures Surgical Care Improvement Project • Prophylactic antibiotic received within 1 hour prior to surgical incision • Prophylactic antibiotic selection • Prophylactic antibiotics discontinued within 24 hours after surgery end time • Surgery patients on beta-blocker therapy prior to admission who received a beta blocker during the perioperative period • Surgery patients with recommended venous thromboembolism prophylaxis ordered • Surgery patients with recommended venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery • Urinary catheter removed on postoperative day 1 or postoperative day 2 • Surgical patients with perioperative temperature management Pneumonia • PN-3b blood cultures performed in the emergency department prior to initial antibiotic received in hospital • PN-6 initial antibiotic selection for CAP in the immuno-competent patient • Heart Failure • ACEI or ARB for LVSD • LVEF assessment Acute Myocardial Infarction • Aspirin prescribed at discharge • Statin prescribed at discharge The award presentation will be made sometime this fall. Participating in the award ceremony will be Jeffrey Rivest, Chief Executive Officer and President of UMMC; Jonathan Gottlieb, MD, Senior Vice President and Chief Medical Officer; Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer; Ingrid Connerney, DrPH, MPH, RN, CPPS, Senior Director of Quality and Safety; and Ella Giles, MSN, MBA, RN, HACP, Director of Regulatory and Compliance Affairs. Also participating will be the nursing staff from the Regulatory and Compliance Department: Crystal Evans, BSN, RN, Senior Core Measure Coordinator, Patricia Dumler, BSN, RN, Quality Measure Coordinator, Anna Marie Moko, MBA, BSN, RN, Quality Measure Coordinator, and Sylvia Daniels. The Regulatory and Compliance department staff is to be commended for its dedication and facilitation of continuous improvements in our core measure performance, which made this award possible. However, without the hard work and support of the physician, nursing, and ITG staff, we could not have achieved this accomplishment. For the 2014 Excellence Award the following measures will be added: • HF-1 Discharge Instructions • IMM-1a-Pneumcoccal Immunizationoverall rate • IMM -2-Influenza Immunization There will be significant changes for the 2015 Excellence Award: • Hospitals will be required to have an individual performance score of 95% or above on all measures. This is a change from the 90% minimum for the 2013 Award • Hospital must pledge to submit the outpatient measures (see Spring 2013 issue of News and Views) • The hospital must have a performance measurement of 95% or above on all measures in one measure set (AMI, Chest Pain, ED Throughput, Pain Management, Stroke or Surgery) of the out-patient measure set • VTE measures 1, 2, 3, 4 and 5 will be added (see Summer 2012 issue of News & Views) 9 10 Summer 2013 Nurse Practitioner Education: Extending Collaborative Practice to Korean Students Rachel Hercenberg, BA, Project Specialist, CPPD and Carmel McComiskey, DNP, CRNP, Director of Nurse Practitioners For many years, University of Maryland Medical Center’s nurse practitioners have been recognized as leaders in advance practice nursing. This year, the UMMC NPs have extended this influence internationally. For the past six years, under the leadership of Carmel McComiskey, DNP, CRNP, Director of Nurse Practitioners, has contracted with Sue Song, PhD, APRN, Clinical Instructor, UM School of Nursing, to host a site visit for nurse practitioner students from the Sungkyunkwan University (SKKU) in Korea. SKKU is the oldest university in East Asia, founded in 1398. In 2013, SKKU selected 16 nurse practitioner students to travel to the University of Maryland Medical Center for a week-long site visit from May 20 – May 24. This visit was coordinated by the Department of Clinical Practice and Professional Development staff members Rachel Hercenberg, BA, Project Specialist and Cyndy Ronald, BA, Manager, School of Nursing Partnership Programs. Dr. Song considers this opportunity “a valuable and meaningful experience for the faculty and students in Korea,” since it provides the students “a chance to compare and contrast the NP practices and develop the vision for their profession.” She also emphasizes the benefits to U.S. staff: “It provides the ability to compare practice with Koreans and to increase their appreciation of the need to overcome cultural and language barrier and to teach diverse staff.” The students spent the first morning at the University of Maryland School of Nursing, with tours of the simulation laboratories and the learning facilities. That afternoon, they joined UMMC NPs Kim Reck, CRNP, Clinical Program Manager, and Marguerite Russo, MS, CRNP, who welcomed the students and taught them about the advanced practice role both in the U.S. and specifically, the Medical Center. The students also learned about advanced practice nursing outcomes from Marian Grant, DNP, CRNP and nurse research and evidence-based practice from Lynnee Roane, MS, RN, Nurse Researcher, Clinical Practice and Professional Development. The group was provided with medical center tours led by Clinical Practice & Professional Development Project Specialists (Tia Milburn, BA, Erica Bergstein, MS, Nelia Zhuravel, BS, and Rachel Hercenberg, BA), where they frequented a number of locations, including the Trauma Resuscitation Unit, the helipad, the Patient Placement Center and the General Operating Room. The SKKU students spent the majority of their week in clinical rotations on units that were chosen specifically to match their clinical interests. A number of enthusiastic preceptors welcomed students into areas from Oncology, the Advanced Heart Failure Service, and Oncology, Pediatric Hematology-Oncology, Trauma and Critical Care. John Hagan, MS, CRNP-AC, CCRN even shared YouTube links for learning basic Korean with the fellow preceptor group. Preceptors included: MICU Team Lou Ellen Lallier, MS, APRN-BC John Hagan, MS, ACNP-AC, CRNP, CCRN STC Team Amy Borth, MS, CRNP Brooke Anderson, MSN, ACNP Sherry Cummin, MS, CRNP Kristie Davalli, MS, CRNP Oncology Team Michelle Turner, MS, CRNP Diane Keegan Wells, MSN, CPNP Interventional Radiology Mihae Shin Diep, MS, CRNP, ACNP, CCRN Advanced Heart Failure Service Team Robin Miller, MSN, MPH, ACNP Valarie Harbaugh, MS, CRNP Ayo Mandi, MS, CRNP Susan Yi, MS, CRNP continued on page 11. Nurse Manager Brigid Blaber with Korean student nurses from Sungkyunkwan University news &views Nurse Practitioner Education Extends to Korea, continued from page 10. Korean NP Student Certificate Ceremony 2013, with Dr. McComiskey and Dr. Song “I am amazed at the UMMC NP role. They are actually demonstrating NP practice according to the standard. Furthermore, they are so proud of themselves as NPs. They take time to explain areas to me that I don’t understand even though they are so busy.” Students interested in nursing administration shadowed our nurse managers including Mary Jo Simke, MS, RN, Nurse Manager, PICU (Pediatrics), Brigid Blaber, MS, RN, Nurse Manager, NeuroCare ICU (Neuro ICU), and Theresa Melville, BSN, RN, OCN, Nurse Manager, Greenebaum Cancer Center (Cancer). The team voiced special appreciation to Susan Yi, MS, CRNP and Mihae Shin Diep, MS, CRNP, who were special advocates due to their Korean language proficiency and welcoming nature. The week closed with a certificate ceremony, where students received a certificate of attendance from Dr. McComiskey and Dr. Song and posed for many photographs to remember their experience with the team. UMMC received overwhelmingly positive feedback from the entire experience. Dr. Song stated, “It is amazing to see UMMC staff extend their hospitality and be willing to learn a different culture. I highly recommend this international exchange program.” Feedback indicated that Korean students were most impressed with the independent role of the Advanced Practice Nurse in the U.S., which differs greatly from the way the APN scope is framed in Korea. Student evaluations from SKKU read: “It was really eye-opening experience for me … Specifically, I was impressed about their teamwork with the treatment team — their ability to present the case with confidence, communicate freely about their knowledge about the case, and take a time to teach the patients and their family.” “I’d like to recommend this program for the incoming students and professors. I think some of the professors need to make an observation and discussion about the new changes for the standard of practice and the best practices.” For six years, UMMC has had the unique opportunity to spend a week with these Korean NP student visitors, providing meaningful learning opportunities for both the visitors and the staff. UMMC is grateful to showcase our practices and for this collaborative relationship with our Korean colleagues. The team looks forward to this visit each year. 11 12 Summer 2013 2013 STUDENT NURSE RESIDENCY PROGRAM The UMMC Student Nurse Residency Program has just completed its seventh year. The residency is a ten week summer internship program for BSN students entering their final year of nursing school. This year, there were 51 students from 10 area nursing schools, Placements included units ranging from acute care to critical care, and included a variety of specialties, which were chosen based on each applicantâ€™s personal interests. The students worked one on one with a nurse preceptor, attended education classes, completed bi-weekly journals and completed an evidence-based practice project which resulted in a collection of posters which were displayed in the Weinberg Atrium on July 25 and 26. Again this year, we were fortunate to have high caliber participants who experienced the best that UMMC has to offer. While we normally celebrate the students, this year we are celebrating the Medical Center. Through their journals, conversations and evaluations, the students could not say enough good things about their time here. The unit staff, preceptors, senior leadership and everyone that the students interacted with, embraced them, supported them and offered multiple opportunities for learning. Because of this incredible experience, the students feel they are well on their way to transitioning from student to new graduate nurse emulating the positive professional behaviors they witnessed. The following are some excerpts from journal entries submitted these past 10 weeks speaking to the UMMC culture. Student Nurse Residents 2013 news &views 13 ‘‘ I am in love with the L&D unit. They are very supportive, interesting, compassionate people who care a lot about providing good patient care. I have a lot to learn from them about how to provide good patient care and still have effective time management… The nurses work so intricately with professionals from other disciplines that it is fascinating to watch and efficient to execute.” Labor & Delivery Student Nurse Resident ‘‘ The care of a patient is truly a team effort. I am impressed by the teamwork and communication by all of the people taking part in a patients’ care on a daily basis. One patient who I took care of needed quite a bit of extra help. I was amazed to see how social work, housekeeping, our nurse manager, the NP, and all the others who helped in his care came together to increase his satisfaction of our hospital. I was glad to see everyone going above and beyond to make sure that the patient was satisfied with how he was being cared for (while in the CCU).” CCU Student Nurse Resident Travis Spencer with his poster, “Delirium in the ICU” ‘‘ The staff on 4STA has been amazing. The entire unit is like a family and is so willing to help one another. They made me feel welcome on day one and continued to help me with anything that I may have needed to this day. I am very grateful to have been in such a healthy work environment. I now see how a hospital unit can work and I am really energized to add my input wherever I may work.” 4STA Student Nurse Resident Women’s and Children’s student nurse residents with Program Manager, Cyndy Ronald ‘‘ ‘‘ I have been exposed to so many experiences and gained such knowledge and skill. I am infinitely grateful to my preceptor who will forever be the first nurse to ever truly mold me into the kind of nurse I strive to be. I am also grateful to the entire BMT unit for welcoming me so openly and kindly. My patients have been the most inspiring — and I now have a new high standard of the quality team I want to be part of when I start working as a RN.” BMT Student Nurse Resident The nurses on the SICU are truly incredible people; their compassion, work ethic, knowledge, and abilities are beyond compare to any that I’ve worked with in the past. Many of them have gone out of their way to orient me to the unit, expose me to new and interesting experiences, and teach me what I need to know to provide the best quality of care possible. I have such an enormous respect for them, and I hope that one day, I can be somewhere close to the level that they are on.” SICU Student Nurse Resident ‘‘ I have had such a great experience at the MICU and could not have asked for a better placement for a unit and preceptor. I am so thankful for this amazing experience and hope to carry on this knowledge and skills throughout the rest of my school and nursing career.” MICU Student Nurse Resident Danielle Luers with her poster, “Necrotizing Enterocolitis with Probiotics” 14 Summer 2013 Journal Club Hot Topics Making the Transition to Nursing Bedside Shift Reports Katrina Daye-Whitehead BSN, RN PCCN CNII C5E/Vascular Surgery Progressive Care Unit Katrina Daye-Whitehead from the Vascular Surgery Progressive Unit (C5E), hosted the July Journal Club meeting to review the article “Making the Transition to Nursing Bedside Shift Reports” (Wakefield et al., 2012).1 The purpose of this study was to improve nurses’ communication with patients during patient handoff and to improve nursing-specific patient satisfaction scores. Patient satisfaction scores were consistently low on an inpatient step-down nursing unit in a midwestern academic health center that typically treated cardiology, internal medicine, trauma and general surgery patients. The 20-bed unit had an average daily census of 16.8 and 32 full-time RNs. The unit was a part of a pilot study to increase nurse-specific patient satisfaction scores by transitioning from shift handoffs that do not involve patients to shift handoffs that involve patients. The goal of transitioning to bedside shift reports was to increase patient satisfaction scores to at least the 90th percentile. The redesigning of the shift handoff began in February 2009, which included review of nurse-specific patient satisfaction scores, current shift report process, and identifying barriers to moving to bedside reports. Super users were identified, training and practice in mock bedside shift reporting began and ongoing discussion of patient satisfaction scores occurred. Nurses were required to educate the patients about the process and reminded to contact the patients 30 minutes prior to the shift and encourage them to ask questions. Patient and family education on the bedside shift report occurred during admission to the unit. Bedside shift report implementation began in June 2009. A post-implementation survey was conducted with 23 nurses about the transition to bedside shift report. On the first follow-up survey, there was an overall agreement that bedside shift reports improved nurse-to-nurse communication and information quality and usefulness, allowed a smoother transition experience for patients and was positively received by patients. Nurses tended to agree with the statement “I prefer shift handoff at the bedside.” There was slightly less agreement on items such as “easier for me to come up to speed on patients not previously cared for.” There was not universal agreement on whether the bedside reports required more time to complete or whether it was more difficult when there was more than one offgoing nurse to obtain reports. Nurses on the unit prefer handoffs at the bedside. Patient satisfaction scores were monitored 6 months pre-implementation and at 6 and 23 months postimplementation of bedside shift reports. In the first 6 months postimplementation, patient satisfaction scores were below the 90th percentile; for the 23 months post-implementation there was little overall improvement with percentiles range between 60th-75th. Scores between January 2010 and May 2011 revealed lower patient satisfaction scores; postimplementation data indicated monthto-month fluctuations in the scores. The percentile rankings for the first 6 months improved; all items questioned on the survey were above the 90th percentile. Averaged scores were between the 5th and 30th percentiles for 7 months, 70th and 89th percentiles for 5 months and >90th percentile for 11 months. Nursing staff satisfaction postimplementation survey was conducted in October 2009 and February 2011; 20% percent of the nurses stated that shift reports were being conducted at the patient’s bedside less that 60 percent of the time; 13 percent of the RNs reported that bedside report occurs 60-70 percent of the time. There were numerous limitations in this study related to the lack of research on bedside shift reports. The pilot study pertains to only one nursing unit in an academic medical center. Since there were low patient response rates (22-35 percent) and a limited number of completed patient satisfaction surveys (8-25 per month), the data may not be representative of the patient population cared for on the unit. This study is more of a process improvement project; bedside reporting may improve patient satisfaction, but there are other contributing factors that control patient satisfaction. The study suggests that bedside reporting increased patient satisfaction to the desired goal of >90th percentile but it also states that there was a fluctuation in the patient satisfaction score. At UMMC there are a few units who have transitioned to bedside shift reporting; C5E initiated “Complete Bedside Shift Report” and just as the study states, there have been barriers and challenges to the change. The goal on C5E is not so much to improve patient satisfactions scores, but to increase patient safety. Discussion: ◗◗ Group agreed that bedside reporting has been inconsistent throughout the organization and units that initiate this activity have not consolidated as standard practice. ◗◗ They agreed that patients have a right to know about their medical information in a transparent way. ◗◗ Some of the perceived bedside reporting advantages were: catching errors, providing information to patients; opportunity to ask questions; opportunity for bedside safety checks; improving patient safety; and provider accountability for patient care. Also, assignment of same patients and consideration of their geographical location may decrease report time. ◗◗ Some of the perceived disadvantages were: lengthier rounds, lack of accountability and buy in among staff; fear of breaching confidentiality and privacy; fear of losing autonomy; and interruptions by patients and families. ◗◗ UMMC units that have successfully implemented bedside rounding engaged charge nurses and senior clinical nurses as drivers of this practice change. Nurse managers held staff accountable, senior leadership performed rounds to sustain practice, and patient care techs were also engaged in the process. ◗◗ Group concluded that bedside shift report implementation takes time, especially to incorporate it in our adopting new practices in place of traditional forms of shift report. 1 Wakefield D, Ragan R, Tregnago M. Making the transition to nursing bedside shift reports. The Joint Commission Journal of Quality and Patient Safety, 38(6); pp 243 news &views UMMC Staff Presentations & Publications In FY 13, UMMC staff presented numerous oral and poster presentatons. Many staff also had manuscripts accepted for publication. Congratulations to our accomplished staff! Presentations Armstrong, C. & DiBlasi, C. (2012, October). Improving the effectiveness of diabetes care visits through computer-assisted analysis of blood glucose readings. (Poster). 2012 American Nurse Credentialing Center National Magnet Conference, Los Angeles, CA. Alton, S., Grau, D., MacHamer, J., Mayzel, M., & Shippen, C. (2012). Improving labor support for patients in an urban, academic medical center — an evidence based practice project. Abstract Association of Women’s Health, Obstetric and Neonatal Nurse Convention, Washington, DC. Bigelow, B., Channing, S., Hearson, L., Nguyen, T., Nickel, J., & Kaiser, K. (2013, April). Standardization of neurologic assessments for patients receiving high-dose cytarabine. (Poster). 38th Annual Oncology Nursing Society Congress, Washington, DC. Clapp, D., Larsen, A., Seidl, K., & Stein, D. (2013, April). Improving efficiency in trauma patients: Preventing repeated imaging, radiation exposure, and increasing practitioner satisfaction. (Poster). Shock Trauma Nurses 16th Annual Conference, Las Vegas, NV. Couchman, C., Mather, C., Salvato, C. & Spencer, M. (2013, May 9). HeartCode 201: Taking your heart code to the next level. (Webinar). Healthstream Inc., Nashville, TN. Faddoul, B.; Connerney, I.; Murphy, L.; Gottlieb J.; Rowen, L. (2012). Understanding the Second Victim: An Organizational Responsibility. University Healthcare Consortiums Annual Conference. Gent, P. (2013, May). The importance of screening for obstructive sleep for obstructive sleep apnea (OSA). (Podium). Society of Gastroenterology Nurses and Associates 40th Annual Course, Austin, TX. Gent, P. (May, 2012). The importance of screening for obstructive sleep apnea (OSA) in the endoscopy suite. Student Graduate Nurses Association 39th Annual Course, Phoenix, AZ. Gent, P., Grasso, G. & Deli, S. (2012). Educational program for endoscopy nurses on obstructive sleep apnea. Student Graduate Nurses Association 39th Annual Course, Phoenix, AZ. Hanif, A., Johnson, V., Lewis, A., & Rosales, V. (March, 2012). Bedside blood glucose monitoring and coverage: When should insulin be given after blood glucose test? 2012 Nurse Resident Program Annual Meeting, Amelia Island, FL. Hastings, E., Hartman, A., & Rachbeisel, J. (2012, November). Integrating physical and mental health treatment in the seriously mentally ill population. (Poster). American Psychiatric Nurse Association 26th Annual Conference, Pittsburg, PA. Huffines, M., Ralls, M & Calderon, D. (2012). To clot or not to clot: Demystifying the coagulation cascade. National Teaching Institute, Orlando, FL. McFadden-Cain, J., Fenton, J., Pumfries, Y., Widmer, C., & Rodriguez, J. (2011). A nurse initiative to improve population health through timely colorectal cancer screening. 2011 American Nurses Credentialing Center National Magnet Conference, Los Angeles, CA. McQuillan, K. (2013, April). International nursing collaborative to reduce central line acquired blood stream infections. (Podium). Society of Trauma Nurses 16th Annual Conference, Las Vegas, NV. McQuillan, K., Thurman, P., Von Rueden, K., McDavid, B., Gilmore, R., & Bayne, T. (2012, October). Impact of nursing council participation in reducing CLABSI. (Podium). 2012 American National Credentialing Center National Magnet Conference, Los Angeles, CA. Hunt, D. (2013, May). The STEMI bridge-team: New approach to cardiac emergency management. (Poster). National Teaching Institute and Critical Care Exposition, Boston, MA. Nickel, J. (2013, April). Obtaining tacrolimus levels through a central line vs. peripheral blood draw: An evidenced based review. (Podium). Oncology Nursing Society 38th Annual Conference, Washington, DC. James, T. (2012). An evidence based approach to minimizing oxygen injury in neonates. Nursing excellence through transformational leadership & innovation, Baltimore, MD. Noll, C. (2011). New graduates in psychiatric nursing: Establishing best practices from the start. American Psychiatric Nurses Association 25th Annual Conference, Anaheim, CA. Joyell, A. (2011). Reducing health disparities in African — American communities. Association of Black Psychologists Conference, Arlington, VA. Noll, C. (2012, November). Best practice by design: Anti barricade doors - inpatient psychiatry. (Poster). American Psychiatric Nurse Association 26th Annual Conference, Pittsburg, PA. Kaiser, K., Bennett, M., Bower, C., & Watson-Evans, S. (2012, September). Development & evolution of an evidence-based protocol nurse directed pain service. (Podium) American Society for Pain Management Nursing, Baltimore, MD. Kaiser, K., McGuire, D., Soeken, K., Reifsynder, J., & Keay T. (2012, September). Challenges and approaches to pain assessment research in non-communicative palliative care patients in an acute care setting. (Podium). Council for the Advancement of Nursing Science, Washington, D.C. Lima, L., Jefferson-Hall, C. Wieber, M., & Woltz, P. (2012, July). I have done the work…How do I showcase it for professional advancement? (Poster). National Nursing Staff Development Organization: Revolutionizing Healthcare Education, Boston, MA. Noll, C., Falck, Z., Clayton, D. Brumbles, D., & Hedden, N. (2012, November). Safety, violence and recovery in the psych emergency department: Paradigm changes and the reduction of seclusion and restraint. (Poster). American Psychiatric Nurses Association 26th Annual Conference, Pittsburgh, PA. Noll, C. (2013). Implementing a peer support program: Making the recovery model real, relevant and vibrant. American Psychiatric Nurses Association, 27th Annual Conference, San Antonio, TX. Page, J. (2012, November). Medical emergencies in inpatient psychiatry: Preparedness for best possible outcomes. (Poster). American Psychiatric Nurses Association 26th Annual Conference, Pittsburgh, PA. continued on page 20. 15 16 Summer 2013 Rounding Report, continued from page 1. infusing through their IVs are appropriate for them and their care plan. Care providers hold similar expectations. They expect medications are what their labels say they are, instruments are sterile if indicated, and colleagues are competent. A high reliability organization (HRO) hospital has consistent performance at high levels of safety over long periods of time. The safety culture of an HRO is dependent on the constant awareness of possible failure. It is this possibility of failure that should keep everyone focused on safety, at all times, so it can be addressed immediately. Collective mindfulness (Weick and Sutcliffe, 2007) features prominently in the culture of HROs. This is where all of us, as individuals and teams, are acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse outcomes (Chassin and Loeb, 2011). We ask the question, “How have we harmed or almost harmed a patient since the last time we met?” in order to remain mindful of the fact that hundreds of thousands of patients are unintentionally harmed in American hospitals every year. Mindfulness helps us uncover safety concerns before they actually harm a patient. We intentionally identify safety and quality issues when they can be fixed, rather than missing the opportunity and harming a patient. Once potential deficiencies in the safety process are identified, our goal is to use powerful tools to eliminate the deficiencies and improve the process. At the Medical Center, these tools are part of our Lean Process Innovation work and are robust in their ability to solve challenging safety and quality problems. Tools alone are not enough; we couple them with a systematic approach that: • Reliably measures the magnitude of the problem • Identifies the root cause(s) of the problem • Finds solutions for the most important causes • Ensures the effectiveness of those solutions • Ensures sustained improvements over time According to Chassin and Loeb (2011), there are three interdependent and equally critical requirements for achieving high reliability. First, clinical and administrative leadership at all levels must be committed to a long-term process. Second, a safety culture that involves mutual trust, safety-event reporting and improvement of problems is essential. Third, robust process improvement and innovation must exist to take a systematic approach to help us understand safety problems and guide us to create and implement highly effective solutions. The aviation and nuclear power industries succeed in reliably preventing harm through the approaches I’ve listed above, but there is one more feature they have that all hospitals need to cultivate: They pursue a zero-defect environment. They set the ultimate goal at zero safety defects. Is a zero-defect environment possible in a medical center? To date, no hospital anywhere has a zero-defect environment. Some, however, are closing in on certain processes such as hand hygiene, readmissions and surgical site infections (May, 2013) We must be committed to change and we must have aggressive targets. Will we reach a zero-defect environment? It may take years to reach, but how can we be committed to anything less? Why would we be committed to anything less? What if it were for someone you love? Would you accept anything less? In the coming months, you will hear more about our Lean Process Innovation work and the Plan, Do, Study, Adjust (PDSA) Model. There will be many opportunities for you to get involved as an individual and team. Speak out about your safety concerns. Use the PDSA Model to innovate new, improved and safe processes. Collectively, we must be mindful, committed and unwilling to settle for anything less than moving toward a zero-defect safety culture. References Chassin, M.R. & Loeb, J.M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs 30(4), 559-568. Weick, K.E. & Sutcliffe, K.M. (2007). Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco (CA): Jossey-Bass; 2007. May, E.L. (2013). The power of zero: Steps toward high reliability healthcare. Healthcare Executive, p.16-24 The Plan, Do, Study, Adjust (PDSA) Model From: (http://www.institute.nhs.uk/quality_and_service_improvement_tools/ quality_and_service_improvement_tools/plan_do_study_act.html, last accessed on July 26th, 2013) What is it and how can it help me? You can use plan, do, study, adjust (PDSA) cycles to test an idea and temporarily trial a change and assess its impact. The four stages of the PDSA cycle: Plan the change to be tested or implemented Do carry out the test or change Study examine data before and after the change and reflect on what was learned Adjust plan the next change cycle or full implementation When does it work best? You may not get the results you expect when making changes to your processes, so it is safer, and more effective to test out improvements on a small scale before implementing them across the board. Adjust Plan the next cycle Decide whether the change can be implemented study Complete the analysis of the data Compare data to predictions Summarise what was learned plan Define the objective, questions and predictions. Plan to answer the questions (who? what? where? when?) Plan data collection to answer the questions DO Carry out the plan Collect the data Begin analysis of the data continued on page 18. news &views Spotlight on Pharmacy Improving Medication Safety through Technology Rachel Flurie, PharmD, PGY2 Pharmacotherapy Resident and Neelesh Vaidya, PharmD, Clinical Pharmacist DoseEdge® Pharmacy Workflow Manager is a technology first introduced to the market in 2007 by Baxa Corp. with the purpose of cutting down on intravenous (IV) drug preparation errors in the health system pharmacy. The system was implemented into the inpatient IV lab at the University of Maryland Medical Center’s (UMMC) central pharmacy in 2009 and most recently into the Katz oncology specialty pharmacy in 2012. Jennifer Nishioka, PharmD, Katz pharmacy manager, played a huge role in developing the DoseEdge® system and integrating it into Katz. She described the preparatory work which included a testing phase to create a drug database for the system, a training phase in which Baxa Corp. provided detailed instruction to pharmacy staff, and a go-live phase where Baxa Corp. had a project manager on-site to help with the transition. In the end, DoseEdge® has proven to help the pharmacy department better manage its IVs in several ways: 1. Promoting Safety: Prior to DoseEdge®, pharmacists were checking IVs using the syringe pull-back method. Pharmacy technicians would compound the IV and then retroactively pull back the syringe to show the amount of drug and diluent used. DoseEdge® helps to reduce key sources of preparation errors, including wrong dose and wrong drug as well as look-alike/sound-alike drugs. With the help of barcode technology, each vial is scanned to prepare the dose. Barcode scanning provides safety and accountability as every vial and diluent must be scanned first in order for the dose to be prepared. For example, while preparing Rituximab® 800 mg, the DoseEdge® system requires the technician to scan all eight vials (100 mg each) into the system before he or she can proceed with dose preparation. Dr. Nishioka ran an error report in Katz pharmacy from January 17, 2012 through October 21, 2012 and found that the system detected and prevented 150 errors in that timeframe. Of those, 49 were selection of incorrect drug and 101 were selection of incorrect diluent. Of the 101 incorrect diluent, 29 of them would have been compounded in incompatible solutions and would have been discarded. 2. Reducing Waste: All doses are sorted and labels are printed only when doses are ready to be prepared, thus preventing a cause of missing doses or dose remakes. The safety features of DoseEdge® also help reduce waste by catching errors that would potentially lead to having to waste a product. 3. Improving Visibility: Reporting functions within DoseEdge® allow analysis of error rates, trending of workloads, and other productivity measures. All of the verification details are stored in the system for future access. When verifying, the system allows pharmacists to zoom in and rotate individual doses for careful review of exact volumes, lot numbers, expiration dates, etc. 4. Increase Efficiency: DoseEdge® permits users outside of the clean room to handle calls regarding dose status as a way to minimize interruption of sterile dose preparation. Additionally, in the Katz pharmacy, oncology nurses can view the dose preparation progress on the screen at their nursing station, thus saving them an extra phone call to the pharmacy. Similar to Katz pharmacy, the pediatrics pharmacy compounds medications for a patient population where exact dosing is critical. In the near future, this same technology that has been shown to increase efficiency of compounding, increase safety features to prevent medication errors, and decrease drug cost due to reduced waste will be implemented into the pediatrics pharmacy. As with any new system and process, there will be a learning curve to overcome. Fortunately, DoseEdge® has been at UMMC since 2009 and many of the kinks have already been worked out. Having the previous experience of seeing its implementation in the Katz pharmacy from beginning to end, the pharmacy department will be well equipped to ensure a smooth transition into the pediatrics pharmacy. Teamwork among all members of the healthcare system will play a big role. And in the end, the process of compounding and administering IV medications will be better for the pharmacy department, for the nurses, and most importantly, for our patients. 17 18 Summer 2013 Rounding Report, continued from page 16. Using PDSA cycles enables you to test out changes before wholesale implementation and gives stakeholders the opportunity to see if the proposed change will work. Using the PDSA cycle involves testing new change ideas on a small scale. For example: • Trying out a new way to make appointments for one provider or one clinic • Trying out a new patient information sheet with a selected group of patients before introducing the change to all clinics or patient groups • By building on the learning from these test cycles in a structured way, you can put a new idea in place with greater chances of success As with any change, ownership is key to implementing the improvement successfully. If you involve a range of colleagues in trying something out on a small scale before it is fully operational, you will reduce the barriers to change. Why test change before implementing it? • It involves less time, investment and risk • The process is a powerful tool for learning; from both ideas that work and those that don’t • It is safer and less disruptive for patients and staff • Because people have been involved in testing and developing the ideas, there is often less resistance How to test: • Plan multiple cycles to test ideas. You can adapt these from the service improvement guide so there is already evidence that the change works • Test on a really small scale. For example, start with one patient or one clinician at one afternoon clinic and increase the numbers as you refine the ideas • Test the proposed change with people who believe in the improvement. Don’t try to convert people into accepting the change at this stage • Only implement the idea when you’re confident you have considered and tested all the possible ways of achieving the change How to use it PDSA cycles form part of the improvement guide, which provides a framework for developing, testing and implementing changes leading to improvement. The model is based in scientific method and moderates the impulse to take immediate action with the wisdom of careful study. The framework includes three key questions and a process for testing change ideas. The Three Questions 1. What are we trying to accomplish? What are our specific aims? 2. How will we know if the change is an improvement? 3. What changes can we make that will result in improvement? What are we trying to accomplish? Teams need to set clear and focused goals. These goals require clinical leadership; they should focus on problems that cause concern, as well as patients and staff. The aims statement should: • Be consistent with any national goals and relevant to the length of the project • Be bold in its aspirations • Have clear, measurable targets • An example of an aims statement from cancer services: Aims: To improve access, speed of diagnosis, speed of starting treatment and patient care of people who are suspected of having bowel cancer. This will be achieved by: • Introducing booked admissions and appointments. Target: more than 95 percent of patients • Reducing the time from GP referral to first definitive treatment to less than 15 weeks • Ensuring that over 80 percent of patients are discussed by the multidisciplinary team Concentrate efforts and measurements on key stages of care: GP referral, first out-patient appointment, first diagnostic test and first definitive treatment. continued on page 19. news &views Rounding Report, continued from page 18. How do we know if the change is an improvement? You will need to measure outcomes, such as reduction in the time a patient has to wait in order to answer this question. If we make a change, this should affect the measures and demonstrate over time whether the change has led to sustainable improvement. The measures in this model are tools for learning and demonstrating improvement, not for judgment. Each project team should collect data to demonstrate whether changes result in improvement. You should report improvement progress monthly on time series graphs known as run charts. Figure 4 PDSA Cycles Running Simultaneously OUTCOMES TO BE COORDINATED What changes can we make that will result in improvement? There are many potential changes your team could make and it is possible that there may be several PDSA cycles running sequentially (figure 3), or even simultaneously (figure 4). Sequential cycles are common when the study reveals results which suggest a different approach is needed. Figure 3 PDSA Cycles Running Sequentially Simultaneous cycles may occur when the changes are more complex, possibly involving several departments. It is important that you identify any interactions between simultaneous cycles, as a change in method in one cycle may alter the impact of another somewhere else. What next? Having identified the changes with the greatest benefits, the next stage is to fully implement the change. This will require a stakeholder analysis, a project management plan and an ongoing analysis of the outcomes. 19 20 Summer 2013 Honorable Mention Professional Advancement Model Promotions Congratulations to the following UMMC nurses promoted in July 2013! Senior Clinical Nurse I Lisa Sliva, BSN, RN, CPN General Peds Kara Swirdovich, BSN, RN 13 East/West April Curran, BSN, RN 4 STA Stacey Mondoux-Owens, BSN, RN Cardiac Cath Lab Katee Paine, BSN, RN, FCCS MICU Erin Oâ€™Grady, MS, RN, OCN, CNL Stoler Pavilion Caitlin Riebau, BSN, RN, CCRN MICU Jodie McKenna, BSN, RN PICU Stephanie Zock, BSN, RN, OCN N8/9W Oncology Christopher Kolokythas, BSN, RN eCare Cameran Baker, BSN, RN 13 East/West Katrina Daye-Whitehead, BSN, RN, PCCN Vascular Surgery, C5E Kristen Ray, MSN, RN TRU Jessica Page, BSN, RN Adult Psych Martha Lusby, BSN, RN Neuro ICU Senior Clinical Nurse II Nancy Corbitt, BSN, RN, OCN, CRNE N8/9W Oncology Sheila Angobung, BSN, RN, CNOR General ORs Tracy Kratz, BSN, RN, CPEN Peds ED Nicole Anthony, BSN, RN, CCRN, CCTN Transplant Surgery, C8 Presentations & Publications, continued from page 15. Rowen, L. (2013). The Ethics of Substance Abuse Among Nurses. Advanced Practice Nursing Grand Rounds, University of Maryland Medical Center, Baltimore, MD. Rowen, L. & Facteau, L. (2013). Leadership from the Perspective of the Chief Nursing Officer. University of Virginia School of Nursing, Charlottesville, VA. Rowen, L. (2013). Disruptive Behavior in the Workplace, Keynote address for Nurses Week, UM St. Joseph Medical Center, Baltimore, MD. Rowen, L. (2013). Serving in the Role of the Transformational Leader. Maryland Organization of Nurse Executives Conference, Baltimore, MD. Rowen, L. (2013). The Ethics of Substance Abuse Among Nurses. Trends in Nursing Practice Annual Conference, Baltimore, MD. Rowen, L. Co-worker Civility: How it affects safety, satisfaction and service (Keynote) Special Topics in Pediatric Nursing, University of Maryland Medical Center, Baltimore, MD Rowen, L. (2013). Keynote address: Care Suffers when communication fails. First Annual Interprofessional Education Conference, UMB, Baltimore, MD. Rowen, L. (2013). Innovative use of Prezi for presentations. University of Maryland School of Nursing DNP Executive Track, Baltimore, MD. Rowen, L. (2013). Leadership to transform the culture. University of Maryland School of Nursing DNP Executive Track, Baltimore, MD. Rowen, L. and Doyle, K. Can Structured Leadership Rounds Improve Patient Outcomes? 2013, American Organization of Nurse Executives Annual Conference Denver, CO Rowen, L. (2013). Promoting Safety and Quality. Scottsdale Healthcare System, Scottsdale, AZ. Rowen, L. (2013). Transformational Leadership. Scottsdale Healthcare System, Scottsdale, AZ. Rowen, L. (2013). A Model for Advanced Practice Nursing. Scottsdale Healthcare System, Scottsdale, AZ. Rowen, L. Being a Transformational Leader at the University of Maryland Medical Center 2012, New Leader Development Course, University of Maryland Medical Center, Baltimore, MD Rowen, L. Safety and Quality: An Imperative for Practice 2012, Northeastern University, Boston, MA Rowen, L. Disruptive Behavior in the Workplace (Keynote). 2012, Advanced Practice Grand Rounds, University of Maryland Medical Center, Baltimore, MD Roche, R., Viswanathan, P., Clark, J.E. & Whitall, J. (2013). Children with DCD can perceive and adapt to perceptible and subliminal rhythm changes. DCD X: 10th International Conference on Developmental Coordination Disorder, Ouro Preto, Brazil. Supplement to Brazilian journal of motor behavior, June 2013, Vol 7, PgS52. Rowen, L., Seidl, K., Raymond, G., Hercenberg, R., & Cafeo, C. (2012, October). Can a brief intervention increase awareness of disruptive behavior in the workplace? (Poster). 2012 American Nursing Credentialing Center National Magnet Conference, Los Angeles, CA. Royster, K., Gambrill, N. Kaiser, K., Schuetz, K., Rigdon, A., Rutter, M., & Woltz, P. (2013, April). Developing, implementing, and evaluating a survivorship program that begins with diagnosis. (Poster). Oncology Nursing Society 38th Annual Congress, Washington, DC. Scala, M., & Tran, K. (2012). Will the combination of a comprehensive isolation procedure and continued education improve nursing compliance with initiating isolation precautions from triage? Nurse residency program annual meeting, Amelia Island, FL. Smith, D. (2013, June). Holistic nursing leadership within an academic medical center: Launching a hospital-based AHNA chapter for education and support. (Podium). American Holistic Nurses Association Conference, Norfolk, VA. Snow-Kaiser, K., Bennett, M., Bower, C., & Watson-Evans, S. (2012). Development & evolution of an evidence-based protocol nurse directed pain service. American Society for Pain Management Nursing Presentation, Baltimore, MD. Stanek, G., Mulligan, K., & Forsythe-Chisolm, L. (2012). The process of assessing and improving patient family centered care in the shock trauma center, University of Maryland Medical Center. 5th International Conference on Patient and Family Centered Care, Washington, DC. continued on page 22. news &views Certification Corner Caroline Weaver, MS, RN, CCRN, FCCS Senior Clinical Nurse I Medical Intensive Care Unit I began my nursing career in March 2010 as a new graduate RN on the Medical Intensive Care Unit. I was somewhat like a fish out of water because my medicalsurgical clinical rotation in nursing school was short in duration on a low-acuity unit, and my nursing school practicum was 300+ hours of rotations in a labor and delivery unit at a community hospital – neither of which adequately prepared me for my new position. Needless to say, as I began my nursing career in the MICU at University of Maryland Medical Center, there were many times during my 16-week new graduate orientation when I questioned my judgment on accepting this position, which was seemingly way out of my league. My manager had assured me during the interview process that she believed I would be nothing short of successful, but initially I was not so sure of myself. Around the time of my one-year anniversary hire date, I was finally feeling more confident with my practice, truly accepted by co-workers, and developed a sense of pride and love for my job. During my first annual evaluation, I set a goal to become a certified critical care nurse (CCRN) by the time of my next evaluation date. This goal seemed both appropriate and attainable at the time, as the MICU was experiencing a huge push from our former nurse educator for nurses to become certified. During this time I also began to question where I wanted to go with my career. I was torn between being promoted to Senior Clinical Nurse or applying for a position in the ICU Supplemental Staffing pool. I decided that having my CCRN certification would be beneficial for me no matter which direction I chose. In February 2012, I successfully achieved my CCRN certification in accordance with my goal timeline, and I have noticed a marked improvement in my nursing practice since that time. Each nurse’s decision to become certified and their timeline of attaining certification is highly individualized. I believe the timing of my certification was perfect for me. I was studying for certification at a time when I was truly beginning to understand the ‘why’ behind patient care. My shifts were no longer just a series of tasks that I had to focus on prioritizing and completing in a timely fashion. Becoming certified really helped me to look beyond the order sets and to ask appropriate questions of the residents and physicians for the patients’ benefit. As a CCRN, I have become a resource to my co-workers and new graduate RNs (albeit an amateur resource, as there are so many skilled, seasoned nurses on the MICU). My growth as a certified nurse on the MICU has been timely, as the acuity of our patient population has increased with the transition in 2012 of the University Specialty Hospital to the new Post-acute Specialty Program at University of Maryland Medical Center Midtown Campus (formerly Maryland General Hospital). Due to this transition, our MICU less frequently treats and boards long-term care and rehabilitation center patients, making beds available for the ever-increasing critically ill patient population that we take pride in providing care for on a daily basis. In addition to improving my skills and expanding my knowledge base as a MICU nurse, obtaining my CCRN certification has led to my successful promotion to Senior Clinical Nurse I (SCNI). Part of my role as SCN I is acting as the CCRN Champion on the MICU. This includes providing fellow co-workers with the most up-to-date information on review courses, the best self-study materials, guidance in test registration and reimbursement process, and overall support in the test preparation process. I also have the pleasure of sitting on the hospital-wide Certification Subgroup, which allows me to connect with fellow certified nurses from various specialties within the medical center. In this forum, we are able to share experiences as certified nurses, ideas about ways to promote nursing certification, and how to best support nurses who are preparing to become certified and those already certified. Involvement on this committee has helped me to better serve MICU nurses interested in the certification process. I believe that certification is vital to nursing in its growth as a profession. As certified nurses, we constantly find ourselves striving for more knowledge and improvement in our practice through continuing education at conferences, selfstudy, etc. According to the American Association of Critical Care Nurses, certification in nursing benefits not only the certified nurse on a resume, but the employing institution. Achieving certification promotes higher RN job satisfaction. More importantly, certified nurses benefit today’s patients as care becomes more complex and our population of acutely and critically ill increases. Since attaining my own certification, I have taken great pride as a CCRN and believe that I have fully reaped the benefits of certification for myself, our great institution of University of Maryland Medical Center, and most importantly for our patients in the MICU and across the Medical Center. I find myself encouraging my colleagues to strive for the same by achieving professional certification and hope to serve as a resource in CCRN certification to my co-workers on the MICU and other units for many years to come. 21 22 Summer 2013 “Every day, we witness the talent, skill, knowledge and expertise of Medical Center nurses and a strong nursing leadership team. The privilege of making a difference in a patient’s life is one we hold sacred”. Lisa Rowen, DNSc, RN, FAAN, Senior Vice President for Nursing and Patient Care Services, Chief Nursing Officer Please take time to review the 2013 Nursing Annual Report for exemplars of the wonderful ways our nurses have made a difference this year. Find it at: http://intra.umm.edu/ummc/nursing/docs/ nursing-annual-report-13.pdf Presentations & Publications, continued from page 20. Stickles, M. (2012). Leveraging competencies to create a sustainable dedicated rapid response team. 7th International Conference on Rapid Response Systems and Medical Emergency Teams, Sydney, Australia. Tanguay, L., Dorsey, S., Couture, D., Renn, C., & Gambill, N. (2011, October). Bench to bedside: Current perception threshold testing (CPT) to measure sensory fiber changes after chemotherapy. STTI 41st Biennial Convention, Grapevine, TX. Thurman, P., Gilmore, R., & McQuillan, K. (2012). Reducing catheter associated urinary tract infections: A nursing process improvement project. Nursing EBP Conference, Baltimore, MD. Trotman, S., Han, N., & Lupisan, A. (2012). Nurse-led intervention to improve screening and treatment for substance abuse: An act of hospitals. Interdisciplinary Nursing Quality Research Initiative National Conference, Washington, DC. Van, K., Hartman, S., Payne, A., Bauman, M., & Stanek, G. (2013, April). Hourly rounding on an acute care trauma unit. Shock Trauma Nurses 16th Annual Conference, Las Vegas, NV. Von Rueden, K. (2013, April). Burnout, compassion fatigue, secondary traumatic stress: Buzz words or the real deal? 16th Annual Society of Trauma Nurses Conference, Las Vegas, NV. Von Rueden, K., Doyle, K., Emerick, M., Joshi, M., McQuillan, K., Rabinowitz, R., Thurman, P. (2012). Delirium in trauma patients: Prevalence and predictors. American College of Surgeons 2012 Trauma Quality Improvement Program Annual Scientific Meeting, Philadelphia, PA. Von Rueden, K., McQuillan, K., Thurman, P., Von Rueden K., Emerick, M., Stein, D., Rabinowitz, R., Manjari, J., Doyle, K., & Scalea, T. (2012, October). Reducing central line associated bloodstream infection in trauma patients: A multifaceted, evidence based approach. American College of Surgeons 2012 Trauma Quality Improvement Program Annual Scientific Meeting, Philadelphia, PA. Von Rueden, K., Thurman, P., Merenda, J., McQuillan, K., Wallizer, B., Blacklock, T., & Son, H. (2012, October). Delirium in trauma patients: Nurse-driven research and evidencebased guideline development. (Podium). 2012 American Nurses Credentialing Center National Magnet Conference, Los Angeles, CA. Wall, M. (2013, April). Rapid improvement event in interventional radiology at the University of Maryland Medical Center. (Poster). Association for Radiologic & Imaging Nursing 2013 Convention, New Orleans, LA. Wallizer, B., McQuillan K., Thurman, P., Son, H., Blacklock, T., Merenda J., Hzke, S., & Dalendkoft, S. (2012). Delirium in trauma patients: Prevalence and predictors. National Teaching Institute & Critical Care Exposition, Orlando, FL. Wilson, P. (2012, November). Successful strategies for clinical and cultural orientation of foreign educated nurses. (Oral presentation). Southern Regional Health Education Center, Asheville, NC. Wilson, T., Kaiser, K., McGuire, D., Pannullo, D., Russo, M., & Wiegand, D. (2012). Assessing acute pain in critically ill patients unable to communicate. National Teaching Institute and Critical Care Exposition , Orlando, FL. Yarbrough, K., Tuszynski, S., Bautista, M., & Blaber, B. (2013, February). Effectiveness in using a staff nurse coach for clinical trial implementation: A winning strategy. (Poster). International Stroke Conference 2013, Honolulu, HI. continued on page 23. news &views Presentations & Publications, continued from page 22. Publications Adeola, R., (In press). Get the message: Distracted driving in teens. Trauma Journal of Nursing. Brumbles , D., & Meister, A. (2013). Psychiatric elopement: Using evidence to examine causative factors and preventative measures. Archives of Psychiatric Nursing, 27(1), 3-9. Cooper, V. & Haut, C. (2013). Preventing ventilator-associated pneumonia in children: An evidence-based protocol. Critical Care Nurse, 33(3), 21-29. McComiskey, C.A., Tyler, R., Rowen, L. (2012). Making the Case for a Nurse Practitioner Leadership Model: A Step by Step Conceptual Map for Nurse Practitioner Integration within Organizations. In Transition into Hospital Based Practice: A Guide for Nurse Practitioners and Administrators. Eds: Bahouth, M.; Blum, K; and Simone, S., p. 69-88. Nahm, E., Stevens, L., Scott, P., & Gorman, K. (2012). Effects of a web-based preoperative education program for patients undergoing ambulatory surgery: A preliminary study. Journal of Hospital Administration, 1(1), 21-29. Esoga, P. & Seidl, K. (2012). Best practices in orthopaedic inpatient care. Orthopaedic Nursing, 31(4), 236-240. Rowen, L. (2012). Childhood Obesity: A Call to Action through Collaboration. Bariatric Nursing and Surgical Patient Care 7(2) 45-47. 38 2013 UMMC Nursing Annual Report. Han, K., Trinkoff, A., Storr, C., Geiger-Brown, J. & Johnson, K. (2012). Comparison of job stress and obesity in nurses with favorable and unfavorable work schedules. Journal of Occupational and Environmental Medicine, 54(8), 928-932. Rowen, L., Hunt, D., & Johnson, K. (2012). Managing obese patients in the OR. OR Nurse, 6(2), 26-35. doi: 10.1097/01. ORN.0000412324.97287.aa. Hazzard, B., Johnson, K., Pugh, T., Russo, B., Wolkowiak, P. & Dordunoo, D. (In press). Work and non-work related factors associated with PACU nurses’ fatigue. Journal of Perianesthesia Nursing. Sattler, B., Randall, K., & Choiniere, D. (2012). Reducing hazardous chemical exposures in the neonatal intensive care unit: A new role for nurses. Critical Care Nursing Quarterly, 35(1), 102-112. doi: 10.1097/CNQ.0b013e31823b2084. Huffines, M., Johnson, K., Smitz-Naranjo, L., Pannulo, D., Ralls, M., Howes, S., Smith. R., Appleby, M., & Lissauer, M. (In press). Improving family satisfaction and participation in decision making in a surgical ICU: A multidisciplinary collaborative quality improvement project. Critical Care Nurse. Seidl, K., & Newhouse, R. (2012). The intersection of evidence-based practice with 5 quality improvement methodologies. The Journal of Nursing Administration, 42(6), 299-304. doi: 10.1097/NNA.0b013e31824ccdc9. Jensen, M., Pease, E., Lambert, K., Hickman, D., Robinson, O., McCoy, K., Barut, J., Musker, K., Olive, D., Noll, C., Ramirez, J., Cogliser D., & King, J. (2013). Championing Person-First Language: A call to psychiatric mental health nurses. Journal of the American Psychiatric Nurses Association, 19(3) 1-6. Kaiser, K., McGuire, D., Soeken, K., Reifsnyder, J., & Keay, T. (2011). Assessing pain in 321 nonresponsive hospice patients: Development and preliminary testing of the multidimensional objective pain assessment tool (MOPAT). Journal of Palliative Medicine, 14(3):287-92. Lee, M., Johnson, K., Newhouse, R., & Warren, J. (2013). Evidence-based practice process quality assessment: EPQA guidelines. Worldviews on Evidence-based Nursing. Makic, M., Rauen, C., & Von Rueden, K. (2013). Questioning common nursing practices: What does the evidence show? American Nurse Today, 8(3), 10-13. Simone, S. Inborn Errors of Metabolism. Pediatric Acute Care Nurse Practitioner Certification Review Book. In Tilford A. & Haut C. (Eds.). Jones & Bartlett. Submitted June 2013. Moss, M. & Simone, S. Physical Design and Personnel Organization of the PICU. In: Rodgers Textbook of Pediatric Intensive Care, 5th Edition. Philadelphia: Wolters Kluver & Lippincott, Williams & Wilkins. Submitted September 2013. Bahouth, M, Blum, K., & Simone, S. (Editors) (2013). Transitioning into Hospital Based Practice: A Guide for Nurse Practitioners and Administrators. Springer Publishing. Simone, S. & Sorce, L. Pain and Sedation. Pediatric Acute Care Nurse Practitioner Certification Review Book. In Tilford A. & Haut C. (Eds.). Jones & Bartlett. Submitted August 2013. Simone, S. Measuring Professional Growth of the Nurse Practitioner. In Bahouth, M, Blum, K., & Simone, S. (2013). Transitioning into Hospital Based Practice: A Guide for Nurse Practitioners and Administrators. Springer Publishing. Duke, C. Simone, S., & Bahouth, M. Nurse Practitioner Orientation. In Bahouth, M, Blum, K., & Simone, S. (2013). Transitioning into Hospital Based Practice: A Guide for Nurse Practitioners and Administrators. Springer Publishing. Resnick, B, Boltz, M., Galik, E. Wells, CL. (2013) Physical Capacity Scale: Psychomotor Testing. Clinical Nursing Research. 22: 7-29 Tarantion, B., Earley, M., Audia, D., D’Adamo, C., & Berman, B. (2013). Qualitative and quantitative evaluation of a pilot integrative coping and resiliency program for healthcare professionals. EXPLORE: The Journal of Science and Healing, 9(1), 44-47. Wells, CL. (2013) Physical therapy management of patients with ventricular assist devices: Key considerations for the acute care physical therapist. Physical Therapy Journal, 93: 266-278. Wells, M. (2013). Elimination of immediate-use steam sterilization of radioactive seed implants. AORN Journal, 97(5), 515-520. Witting, M. & Hydorn, S. (2013). Variation in orthostatic vital sign testing in an urban academic emergency department. Journal of Emergency Nursing. Advance online publication. doi: pii: S0099-1767(12)00435-7. 10.1016/j.jen.2012.08.017. Woltz, P., Chapa, D., Friedmann, E., Son, H., Akintage, B. & Thomas, S., (2012). Effects of interventions on depression in heart failure: A systematic review. Heart & Lung, 41, 469-483. doi: 10.1016/j.hrtlng.2012.06.002. Wright, M., Hebdon, J., Bridson, K., Morrell, G., & Horan, T. (2012). Brief report: Health care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration case study 7. AJIC: American Journal of Infection Control, 40(6), 554-555. Woltz, P. & Moore, A. (In Press). Good clinical practice (GCP): Clinical research best practices. In Klimaszewski, A., Bacon, M., Deininger, H., Ford, B., & Westendorp, J. (Eds.). Manual for Clinical Trials Nursing. Let us know what you’re doing! Nurses’ external scholarly submissions are tracked in the Office of Clinical Practice and Professional Development (CPPD) for outcome reporting to Magnet. For more information, contact Nelia Zhuravel at firstname.lastname@example.org. 23 22 South Greene Street Baltimore, Maryland 21201 www.umm.edu Clinical Practice Update