News and views Spring 2014
NEWS & VIEWS is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center.
news views Spring 2014 A Publication of the Department of Nursing and Patient Care Services University of Maryland Medical Center Magnet Re-Designation: Embedding Excellence into the Culture By Lisa Rowen, DNSc, RN, FAAN Excellence is the quality of being outstanding; excellence is the bedrock of University of Maryland Medical Center nursing. In May, Medical Center nurses were honored with a new four-year re-designation as a Magnet hospital – the American Nurses Credentialing Center’s (ANCC) highest honor for excellence in nursing. The gold standard for professional nursing practice, Magnet recognition provides consumers with the ultimate benchmark for sustained nursing excellence, evidence-based practice, and outstanding patient outcomes. This prestigious designation recognizes how nurses approach their work to actively lead and participate in purposeful initiatives that provide pre-eminent patient care. Magnet recognition positions UMMC among the best hospitals in the nation. Only 7 percent of hospitals in the country have earned this recognition. Left to right: Tia Milburn, BA; Carolyn Guinn, MS, RN; Kristin Seidl, PhD, RN; Lisa Rowen, DNSc, RN, FAAN; and Rachel Hercenberg, MS Our site visit was conducted by a savvy and seasoned appraisal team. They told us that if they ever wanted to return to work at the bedside, they would love to work here. More important, they told us that if they or a loved one ever needed to be hospitalized, they would want to be here because of the nursing excellence they witnessed. Magnet re-designation can be achieved only through the collective efforts of individuals and teams that advance a culture of excellence. Our original Magnet designation occurred in 2009 and now in 2014, re-designation reflects that excellence has been sustained over the years and is embedded in our culture. For nurses at the Medical Center, “living excellence” is not just an expression; it is a way of life. This practice is supported through the strong collaboration nurses have with the other members of the health care team. We would not be recognized as a Magnet health care facility without the broader collaboration between nursing and the individuals in every other department in the Medical Center. This recognition validates the team excellence found here continued on page 10. and is a tribute to every employee. Lisa Rowen's Rounds: PACU receives CNO Award for Team Excellence Lisa Rowen, DNSc, RN, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer In the Medical Center’s Post-Anesthesia Care Unit (PACU), a skilled professional team advances the art and science of perianesthesia nursing through evidencebased practice, focusing on patient and family-centered care. They do all of this with great compassion and flexibility. Comfortable in a dynamic and everchanging environment, the PACU nursing staff does whatever it takes to safely care for patients. The census fluctuates by the hour, depending on the Medical Center’s need to expand beds on any given day. The staff members skillfully accommodate patients across the continuum, from preoperative preparation and post-procedural recovery to boarding of ICU, IMC, and acute patients when the beds on the inpatient units are full. In addition, the staff is crosstrained to care for both adult and pediatric patients. Jim McGowan, DHA, Vice President of Procedural Care Services, says, “This is a team that transcends geography while maintaining their practice focus around the patient populations they serve. You can approach any staff member at any bedspot and the response you will encounter is one that is identical: open, receptive, supportive, continued on page 20. 2 Spring 2014 In This Issue 1 1 2 3 4 6 8 9 12 13 14 16 17 18 25 26 28 30 32 33 34 36 38 39 40 Magnet Re-Designation Lisa Rowen's Rounds Corporate Compliance Acute Care NP Residency Program Watch Your STEP National Occupational Therapy Month Excellence in Hand Hygiene Practices Spotlight on Pharmacy Magnetized... Again! Certification Corner Care Coordination Helping Hands When Change Impacts Patient Care Nurses Week 2014 Hearing Loss and Deafness Understanding the Second Victim Respiratory Cares in CSICU & MICU 2014 Respiratory Care Symposium Nutrition Challenges in Tiny Infants Journal Club Presentations & Publications Achievements I Was Noticed Captain America: Law Breaker Clinical Practice Update Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer, and Martina Sedlak, Director of Compliance & Corporate HIPAA Privacy Officer Each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) or compliance-related news 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: One of my patients took a picture of us together and then sent a copy to me. Is it OK for me to post our picture to my social media page? A: No. Just because the patient wanted you to have a copy of the picture does not give you the authorization to post it on any form of social media. Find News&Views online at http://www.umm.edu/nursing/newsletter.htm and on the UMMC Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm Editor-in-Chief Kimmith Jones, DNP, RN, CCNS, RN-BC Director of Translation to Nursing Practice Clinical Practice and Professional Development Managing Editor Susan Carey, MS Lead, Operations Clinical Practice and Professional Development Associate Editor Mike Costello, MHA Project Specialist Clinical Practice and Professional Development Editorial Board Lisa Rowen, DNSc, RN, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer Suzanne Leiter Executive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice and Professional Development, Neuroscience, Behavioral Health and Supplemental Staffing Chris Lindsley Director, Communication Services University of Maryland Medical System Anne Haddad Publications Editor University of Maryland Medical System 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 and patient care services practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines Send completed articles via e-mail to email@example.com. Please follow the guidelines provided below. 1. Font – Times New Roman – 12 pt. black only. 2. Length – Maximum three double spaced typed pages. 3. Include name, position title, credentials, and practice area for all writers and anyone named in the article. 4. Authors must proofread the article for spelling, grammar, and punctuation before submitting. 5. Provide photos and embedded images in separate .jpg files. 6. Submit trend data in graphic format with labeled axes. 7. References must be numbered consecutively and provided at the end of the article. 8. Editor will seek expert review of articles to verify and validate content. 9. Articles will be accepted based on appropriateness of content and availability of space in each issue. 10. Articles that do not meet the above guidelines will be returned to the author(s) for revision and resubmission. ISSUE Summer 2014 Fall 2014 Winter 2015 Spring 2015 DUE DATE July 8, 2014 October 6, 2014 January 6, 2015 April 1, 2015 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 The Acute Care Nurse Practitioner Residency Program: Promoting Patient Safety and Easing the Professional Practice Transition By Deborah L. Schofield, DNP, CRNP; Carmel A. McComiskey, DNP, CRNP; Tiffany Andrews, MS, CRNP; and Brooke Andersen, MS, CRNP The University of Maryland Medical Center (UMMC) and the R Adams Cowley Shock Trauma Center (STC) have experienced an increased demand for Advanced Practice Providers (APPs), particularly in the past five years. Since 2008, the number of APPs has increased from 67 to 214, largely in the critical care areas. The need for greater numbers of APP providers in critical care has been mirrored nationally, as has the need for transitional (residency or fellowship) programs to focus clinical skills and support APPs during the transition from graduate to provider roles. This sharp increase in need was largely related to the expansion of critical care beds at UMMC/STC, provider shortages due to the impact of the Accreditation Council for Graduate Medical Education regulations (Kleinpell, 2008), increasingly sick and complex patients, and the solidly documented excellent patient care outcomes associated with APP care (Newhouse et. al, 2011). In facing this increased demand for APPs and pursuant to the Institute of Medicine’s (IOM, 2010) recommendation to “promote seamless academic progression” for entry into practice, and an institutionally recognized need to focus APPs on skills related to their role in critical care, a team comprised of nurse practitioners (NPs) and physician leaders convened to create the first post-graduate, critical care nurse practioner residency. Through one year of planning after identifying gaps in practice-based experience and based on feedback from a large survey of UMMC/STC nurse practitioners related to role satisfaction, the residency was launched in 2010. Its primary mission was to ease the graduation to practice transition by providing directed, clinical and didactic immersion activities to promote learning and competency. Now, in its third cohort, the program is fully operational and accredited by the Maryland Nurses Association. This novel program, the first in the Mid-Atlantic region for acute care NPs, has experienced a robust response with each call for applications. The team received 40 applications from acute care NPs across the country during the last call for applications (April 2013). APN residents are full-time employees who are credentialed as NP residents within UMMC/STC and expected to fill open critical care APP roles upon successful completion of the program. The residency is based on a blended framework of the Acute Care Nurse Practitioner Competencies (AACN, 2010) and the Accreditation Council for Graduate Medical Education competencies (ACGME, 2009). The residency includes a nine-month, two-armed program (both trauma and critical care) allowing crossover by electives. The NP residents rotate through many of the critical care units and participate weekly in a full day of didactic offerings which include grand rounds, specialty lectures, case studies, and procedural workshops. Specialty lectures are provided by a wide, interdisciplinary group of content experts which include APPs, MDs, pharmacists, nutritionists, social workers, and addiction specialists. Procedural workshops include chest tube insertion, performance of lumbar puncture, thoracotomy tube insertion, arterial line insertion, suturing, incision and drainage techniques, and bedside echocardiography. In addition, consideration of simulation to enhance additional learning added to the successful experience with practice-based education (Lammers, Davenport, Korley et. al, 2008). The residency program utilizes nationally recognized failure-to-rescue scenarios (when deteriorating patients could benefit from earlier intervention). In concert with the Maryland Advanced Simulation, Training, Research and Innovation (MASTRI) Center and Ali Tabatabi, MD (STC attending physician and co-director of the APN simulation residency program), we successfully launched and integrated the APN simulation program during the second cohort of residents (2011). Residency simulation program preceptors participated in a workshop about simulation and debriefing techniques conducted by Mary Fey, PhD, RN, Director of the Clinical Simulation Laboratory at the University of Maryland School of Nursing. Currently, simulations are conducted twice monthly and can include two to three of over 30 clinically-based scenarios. During each simulation, residency coordinators and MASTRI staff evaluate residents using a standardized scoring sheet which measures their ability to demonstrate critical actions (actions which reflect competency within each scenario). The NP residents are debriefed after each scenario for further learning and feedback. The NP residents complete a survey before and after the nine-month experience. The mean score on the self-perceived procedural skill competency (0 – no skill; 1 – little skill; 2 – some skill; 3 – competency; 4 – expert) has increased from 0 to 3 as of the last cohort. Similarly, the mean pre- and post-observer rating of simulation scenario training has increased from 1 to 3, as of the last cohort. This learning format is so highly valued by the NP residents that newly hired APPs now participate in a focused program that utilizes these aspects of the residency. In addition to evaluation of simulation-based activities, each resident is evaluated by the unit-based APP/MD preceptor at the mid-point and end of each unit rotation. Nationally, NP residencies are proliferating in all specialty areas. To date, there are approximately 26 advanced practice provider residencies spanning from primary care to critical care foci; the first residency for primary care nurse practitioners was developed and implemented by Margaret Flinter, PhD, CRNP, at the Community Health Center in Connecticut (Rauch, 2013). Unlike physician-based residencies, which are funded via Medicare federal subsidies, NP residencies are challenged by varied and sparse funding sources. Many are either institutionally funded or grant-based via private or federal programs. The single federal funding source for nurse residencies, offered by the Health Resources and Services Administration (HRSA), currently focuses on nursing practice in interdisciplinary settings (resident composition is multi-disciplinary) and are non-institutional (HRSA, 2013). UMMC is a member of The University Health Consortium (UHC), an alliance of national academic medical centers and affiliated medical centers, whose mission is to assist member centers to “create knowledge, foster collaboration and promote innovation." (UHC, 2013). The UHC has formed a sub-group of APP leaders who have recognized the need for these postgraduate programs. This UHC sub-group has agreed to gather data that will make a national business case for APP residencies. It is very promising that the American Nurses Credentialing Center (ANCC) has just announced that it will begin credentialing post-graduate APRN continued on page 16. transitional programs (ANCC, 2014). 3 4 Spring 2014 PATIENT CARE SERVICES | REHABILITATION Watch your STEP because Occupational Therapy is ready to take the Lead! Lisa Smoot, OTR/L, UMMC Staff Therapist In the world of rehabilitation, occupational therapy (OT) is often overlooked and misunderstood. At the University of Maryland Medical Center (UMMC), OT is involved in the care of patients of all age groups, with varied diagnoses and in all stages of recovery. Yet, many patients and professionals are still wondering: "What is OT?" The discipline of OT has been in existence since the early 1900s and has evolved by challenging the mainstream medical model of treating patients based purely on their physical symptoms. Occupational therapists are trained to evaluate and treat patients based on a holistic approach that considers not only their physical etiologies, but also psychological, social, economic, and environmental needs. At UMMC, there are two divisions of OT; psych OT under Psychiatry and physical disabilities OT under Patient Care Services (PCS). This article will focus on the physical disabilities division of OT within PCS. Self-Care and MORE! The use of the word occupation is commonly used to mean “job,” as in employment; however, one’s daily occupations encompass all of the meaningful activities, roles, hobbies, habits, and routines that make individuals who they are. This is supported by Pendleton and Schultz-Krohn (2006), who state that, “Occupational therapy practitioners believe that intervention provided for people with physical disabilities should extend beyond a focus on recovery of physical skills and address the person’s engagement, or active participation, in occupation” (p. 5). OTs are educated in task modification, enabling them to break down an activity into its most basic steps and then reteach the activity using adaptive and compensatory techniques. In the acute care setting, OTs are known to help patients relearn Emily Cambronero, how to perform basic self-care, commonly called MS, OTR/L Activities of Daily Living (ADLs). However, the ADLs most meaningful for the ICU patient on the ventilator will differ from the ADLs most meaningful to the orthopedic patient or newborn. At UMMC, occupational therapists provide clinical care on most of the ICUs, IMCs, and general floors, as well as the TRU, ED, and same day surgery. Therapeutic Innovations All occupational therapists have comprehensive educational backgrounds, including psychology, enabling them to assist patients with coping strategies, stress management interventions, and behavior management needs. For a UMMC patient with physical disabilities, typical therapeutic interventions could include: splinting, visual perception, energy conservation, cognitive rehabilitation, ADLs, oral motor development, fine motor development, and upper extremity management. Many UMMC occupational therapists have specialized areas of interest, including pediatric care, spinal cord injury, traumatic brain injury, stroke, cancer, orthopedics, and developmental pediatrics, to name a few. Regardless of a patient's level of care, pride and care is taken in thinking “outside the box” to maximize their level of participation. Education and Scholarly Activity Evidence-based practice, scholarly activity and continued skill development are important and necessary for success within the academic medical center setting. Many UMMC occupational therapists have worked to enhance their skill sets by pursing advanced practice certifications. All pediatric occupational therapists in PCS are certified educators in infant massage (Cheryl Zalieckas, OTR/L, CEIM; Loretta Ferrel, MS, OTR/L, CEIM; and Joanna Stewart, MS, OTR/L, CPST, CEIM). Certified hand therapists (Lauren King, MS, OTR/L, CHT; Laura Brosnan, MS, OTR/L, CHT; and Sharon Cook, OTR/L, CHT) work in the outpatient division of Rehabilitation Services and provide the very delicate care needed to restore patients’ hand/upper extremity function after injury or surgery. Many of our occupational therapists are also certified brain injury specialists, providing care to our patients in the R Adams Cowley Shock Trauma Center and Neurology. Engagement with professional associations has been robust. This fiscal year, Katie Frampton, MS, OTR/L and I were active contributors for the multidisciplinary posters presented during the February 2014 American Physical Therapy Association’s annual Combined Sections Meeting in Las Vegas, Nevada. The posters were titled Implementation of a Behavior Management Strategy to Assist with Ventilatory Weaning: A Case Study of a Long-Term Poly-Trauma ICU Patient and Patient/Family Education Following Traumatic Brain Injury: A Multidisciplinary Approach Across the Continuum of Care. Stewart presented an informative talk titled OT and Child Passenger Safety: Car Seats and Beyond to occupational therapist colleagues during this year’s annual American Occupational Therapy Association conference. Emily Cambronero, MS, OTR/L, contributed by holding the position of vice president of events for the Maryland Occupational Therapy Association. Lastly, the complexity and acuity of the medical center environment positions the UMMC PCS occupational therapist for special opportunities and recognition. Renuka Roche, PhD, MS, OTR/L, is not continued on page 5. news &views Watch Your STEP, continued from page 4. only a specialist in neurology, but she is a sought after speaker and author. Dr. Roche became the first UMMC PCS occupational therapist to earn her PhD when she graduated from the University of Maryland School of Medicine in 2013. Cynthia Roman, MS, OTR/L, CEAS, is an adjunct professor at Towson University, a certified ergonomics specialist, and is working to become a safe patient handling & movement specialist. Wendy Thornton, OTR/L was recognized at the R Adams Cowley Shock Trauma Center gala this year for her outstanding work in patient care and, Michelle Luken, MS, OTR/L, qualified for acceptance into the U.S. Army’s doctoral program. She was one of approximately ten occupational therapists across the nation to qualify for this program. Michelle said that her ability to meet the clinical criteria required by the U.S. Army was due to the vast, “acute and trauma experience gained here at UMMC.” She is currently stationed in San Antonio, Texas and upon graduation will be eligible for deployed psych and trauma brain injury (TBI) missions. Program Development and Process Improvement Occupational therapists are members of interdisciplinary and interdepartmental teams throughout the system striving to improve patient care and departmental processes. They have been involved in staff- and family-education initiatives, including the initiation of “TBI signs” on the neuro-trauma floors in the R Adams Cowley Shock Trauma Center. These signs help to educate both nurses and family members of a patient’s current cognitive status and advise regarding how to maximize the patient’s success. Recent trends in research have highlighted the overwhelming financial value and significant physical outcomes of early mobilization in the ICU (Needham, 2008). At UMMC, occupational therapists are highly involved in supporting this effort through their therapeutic patient interventions and education on safe handling techniques for hospital staff. Diana Johnson, MS, PT, Director of Rehabilitation Services, feels that, “although it is the physical therapist that is commonly thought of when mobility is discussed, it should be understood that occupational therapists are playing an important part, and have been Melissa Kellner, MS, OTR/L Michelle Luken, MS, OTR/L very involved in the UMMC ICU early mobility initiative. Occupational therapists also play a necessary role in patient throughput. Patients recommended for various types of inpatient rehabilitation upon discharge from UMMC don’t only require the professional opinion of the physical therapist. The likelihood of being accepted into an inpatient rehabilitation program upon discharge is largely dependent on the patient having occupational therapy needs as well.” Occupational therapists are involved in multidisciplinary nurse and tech training sessions; work with colleagues across the system as part of the University of Maryland Rehabilitation Network (UMRN); volunteer for community outreach initiatives; and, are using LEAN education (acquired at UMMC) to develop tools to assist with departmental process improvement projects. As you can see, occupational therapy professionals are highly skilled clinicians who are involved in education, process improvement, program development, system initiatives, and leadership. Jason W. Custer, MD, Assistant Professor of Pediatrics, and medical director of the PICU at UMMC, states: “When I think about occupational therapy, I think of therapists using ADLs, dexterity training, and other modalities to help people transition from the acute care environment back to their homes, or in the case of children, back to school. I value their dedication to treating kids like kids, and focusing on family.” References : Needham, D. M. (2008). Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. Journal of the American Medical Association, 300, 1685–1690. Pendleton, H., & Schultz-Krohn, W. (Eds.). (2006). Pedretti’s occupational therapy: Practice skills for physical dysfunction (6th ed.). Philadelphia: Mosby Elsevier. 5 6 Spring 2014 UMMC’s Department of Rehabilitation Services celebrates National Occupational Therapy Month Katie Frampton, MS, OTR/L Occupational Therapy (OT) Month was first established in 1980 as a complement to the American Occupational Therapy Association’s (AOTA) national conference, which took place in April of this year. Occupational therapists at the University of Maryland Medical Center (UMMC), with the support of the Department of Rehabilitation Services, recognized Occupational Therapy Month by participating in several events to raise awareness about the profession, give back to the community, and celebrate and engage in professional activities. UMMC’s occupational therapists were proud and honored to share their talents and expertise with the entire UMMC family during this year’s recognition of National Occupational Therapy Month and look forward to continuing to make positive differences in the lives of our continued on page 7. patients. AOTA President, Ginny Stoffel, PhD, OT, BCMH, FAOTA, inspires thousands of occupational therapists at the AOTA National Conference keynote address. The Conference was held on April 3-6, 2014 at the Baltimore Convention Center. Occupational therapists advocate on Capitol Hill for Conference Hill day. UMMC advanced occupational therapist Joanna Stewart, MS, OTR/L, CPST, CEIM, presents at the conference, “Occupational Therapy and Child Passenger Safety: Car Seats and Beyond.” news &views Opening night at the exposition hall Increasing Awareness at UMMC Complimentary fine motor and grip strength assessments were provided for all interested UMMC staff and visitors. General information about joint protection, arthritis management, and UMMC outpatient services were also provided. The UMMC occupational therapy group worked during lunch breaks to create walker bags for patients being discharged from the hospital to home. Focused on activities of daily living, these bags help patients who are walkerdependent become as independent as possible upon their return home. Physicians were provided with a sweet treat before attending medicine grand rounds â€“ a lollipop with the phrase April is Occupational Therapy Month. OTs â€“ Helping our patients live life to the fullest. Occupational therapists posted pictures of therapists assigned to each nursing unit, and included some interesting facts about the occupational therapy profession, to provide nursing staff with an easy way to identify therapists covering their units. Celebrating our UMMC Occupational Therapists The Department of Rehabilitation Services culminated Occupational Therapy Month by hosting a fun pirate-themed luncheon for all rehab staff. Occupational therapists were recognized for their accomplishments and contributions to UMMC throughout the past year. Right: Kate Heyman, MS, OTR/L, and Emily Cambronero, MS, OTR/L Above: Wendy Thornton, MS, OTR/L 7 8 Spring 2014 Building and Sustaining a Culture of Excellence in Hand Hygiene Practices: An Interprofessional Collaborative Approach Laura Bothe, BSN, RN, PCCN; Lynmarie Figert, BS, RN, PCCN; Katherine Heikes BSN, RN; Vanzetta James, MS, RN, CCRN; Jennifer Motley, BSN, RN, PCCN; and Elizabeth Wingo, BSN, RN, PCCN Keeping hands clean is one of the best ways to prevent the spread of infection and illness (Centers for Disease Control and Prevention (CDC), 2014). The CDC reports that approximately two million patients acquire a hospital-related infection annually and 99,000 die from their infection. Healthcare providers can make a tremendous impact on patient safety and the transmission of infection by washing their hands. In the spring of 2013, Multi-Trauma IMC - 6 (MTIMC 6) hand hygiene shift. The team needed to identify a physician sponsor, executive (HH) rates were below the Maryland Patient Safety Center’s goal of leader and a project leader. After learning about the initiative and ≥ 90%. After learning about an innovative approach that could result role of the physician sponsor, Deborah M. Stein, MD, Associate in improved HH compliance, a meeting was held with Josephine Professor of Surgery, University of Maryland School of Medicine, Brumit, DNP, RN, NE-BC, Clinical Practice Coordinator from the Chief of Trauma, R Adams Cowley Shock Trauma Center, agreed to Quality and Safety Division, who provided information about the support the initiative by becoming the physician sponsor. Karen Joint Commission’s (TJC) HH initiative. In keeping with our mission to E. Doyle, MBA, MS, RN, NEA-BC, Vice President of Nursing and promote the overall health and well-being of our patients, the MTIMC Operations, R Adams Cowley Shock Trauma Center and the Adult 6 team decided in their shared governance meeting to implement Emergency Department, gladly signed on as the executive sponsor, TJC Targeted Solutions Tool (TST) for HH. The TST was developed and Lynmarie Figert, BS, RN, PCCN, CNII, readily agreed to serve as by TJC Center for Transforming Healthcare to improve persistent the project leader. Stein supported the team by role modeling proper health care quality and safety problems related to poor HH (Joint HH and followed up with the medical team whenever additional Commission Center for Transforming Healthcare, 2014). This tool aids HH education or clarification was needed. Doyle supported and health care organizations encouraged the in measuring their HH team via email and MTIMC 6 Hand Hygiene Observed Compliance performance, identifying visits to the unit. As barriers to compliance, project leader, Figert 100% and developing an action encouraged the 90% plan to address obstacles team to complete in performance. The the training video 80% TST provides tips and and quiz and guidelines to sustain implemented the 70% success after the stepdata collection 60% by-step process has process. Brumit been completed. The facilitated the 50% TST allowed members team’s success by of the MTIMC 6 team to collecting, reviewing 40% become educated (via a and providing weekly 30% training video) on proper feedback to coaches HH and how to document on the data, data 20% compliance and nonentry, and coach compliance in a uniform quiz processing 10% manner. TST provided the duties. She provided 0% foundation and framework encouragement and Apr-Jun '13 (En:39 Ex:56) Jul-Sep '13 (En:60 Ex:66) Oct-Dec '13 (En:71 Ex:60) Jan-Mar '14 (En:49 Ex:48) for the MTIMC 6 team to guidance regarding Target Rate Entry Rate Exit Rate Overall Rate improve HH compliance, refocusing the thus contributing team’s efforts and significantly to improvement in patient safety. action planning for improvement. Brumit communicated the team’s The team determined that success of this initiative would concerns about HH noncompliance by staff of other departments and be contingent on the participation of 100 percent of MTIMC 6’s served as assistant and cheerleader throughout the entire process and team: Nurses, PCAs, unit support aides, secretaries, and their nurse continues to encourage the team with each reported result. manager. In May 2013, the MTIMC 6 team began brainstorming and The team realized that in order to create and sustain changes planning the best way to implement this initiative. Consideration in HH practices, they needed to approach HH from a multidisciplinary was given to the data collection requirements and the manpower collaborative perspective. The team felt that in order to be required in obtaining meaningful data. The team formulated a plan successful, they needed to have the entire unit’s buy-in as well as requiring each team member to document two observations per the support of leadership in other disciplines. Response from all shift, allowing them to exceed the required ten observations per healthcare team leaders and other department leaders to engage continued on page 17. news &views Spotlight on Pharmacy The Importance of Medication Reconciliation Eric Isley, PharmD(c) and Kashelle Lockman, PharmD, PGY1 Pharmacy Practice Resident According to the Institute of Medicine, the average hospitalized patient is subjected to at least one medication error each day.1 Up to 40 percent of these medication errors can be attributed to poor medication reconciliation during transitions of care, including hospital admission, transfer between units, and hospital discharge.2 An estimated 20 percent of medication errors during care transitions result in patient harm.2 In 2005, the Joint Commission’s sentinel event database reported that of the more than 350 medication errors leading to death or major injury, nearly half could have been avoided with appropriate medication reconciliation.3 Medication errors that can be prevented by thorough and accurate medication reconciliation include therapeutic duplications, medication omissions, dosing errors, and drug-drug interactions. Proper medication reconciliation can also help to prevent various prescribing and administration errors that could pose harm to patients, such as the writing of error prone “blanket orders.”3 Implementation of effective medication reconciliation has been demonstrated to reduce medication errors. A systematic review by Mueller et al. showed hospital-implemented medication reconciliation interventions reduced medication discrepancies, as well as potential and actual adverse drug events.4 In addition to reductions in clinically significant medication discrepancies and preventable adverse drug reactions, a systematic review by Kwan et al. demonstrated that medication reconciliation potentially reduces longterm readmission rates.5 Because effective medication reconciliation is essential in providing quality patient care, the Joint Commission declared it a National Patient Safety Goal.6 The medication reconciliation process should involve developing and comparing lists of former and current medications, making clinical decisions based on the comparison, and then communicating the most updated list with the next caregiver.7 The foundation of the medication reconciliation process is a complete and accurate medication history that should include all of the patient’s medications (prescription, over-thecounter, herbals, etc.), doses, routes, frequency, and indication.6 To obtain the most accurate medication history, multiple sources of information can be consulted, including patients or caregivers, community pharmacies, recent discharge documents, and clinic notes. It is essential to ask patients how they are taking each medication and when the last dose was taken; don’t assume patients take a medication as prescribed. Many patients independently alter dosing due to side effects or for financial reasons. In addition, a prescriber may have given the patient new instructions that don’t match the bottle the patient brings to the hospital. Medication reconciliation should involve any healthcare worker who is involved in a patient’s transition of care. At UMMC, prescribers are required to perform official medication reconciliation in the electronic medical record, and nurses and pharmacists have a responsibility to ensure each medication a patient receives has been reconciled with their prior medication list. This is equally important at admission, transfer, and discharge. When patients are transitioned from one care setting to another, the discharge or transfer summary often serves as the medication history for the next care setting, so accuracy is crucial. Verbal communication may be warranted for complex medication changes, especially if high-risk medications such as insulin or warfarin are changed. Patients should be provided a complete list of all medications at discharge with instructions for using them. Nurses can ensure patient discharge instructions are complete and accurate by comparing the discharge education medication list to their home list and their inpatient medications. Anyone who notices a discrepancy between lists should seek clarification from the prescriber and ensure the written and verbal instructions for the patient are clear. Effective medication reconciliation is arguably the foundation of patient safety during transitions of care and is a vital component of improving patient outcomes. References 1. Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press; 2006. 2. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307–11. 3. The Joint Commission Sentinel Event Alert. Using medication reconciliation to prevent errors. http:// www.jointcommission.org/assets/1/18/SEA_35.PDF (accessed 2014 Apr 10). 4. Mueller SK, Sponsler KC, Kripalani S, et al. Hospitalbased Medication Reconciliation Practices: A Systematic Review. Arch Intern Med. 2012; 172(14): 1057-1069. 5. Kwan JL, Lo L, Sampson M, et al. Medication Reconciliation During Transitions of Care as a Patient Safety Strategy: A Systematic Review. Ann Intern Med. 2013;158(5): 397-403. 6. The Joint Commission National Patient Safety Goals Effective January 1, 2014. Hospital Accreditation Program. http://www.jointcommission.org/assets/ 1/6/HAP_NPSG_Chapter_2014.pdf (accessed 2014 Apr 11). 7. Barnsteiner JH. Medication Reconciliation. In: Hughes RG. Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Rockville: Agency for Healthcare Research and Quality (US); 2008. 9 10 Spring 2014 Magnet Re-Designation, continued from page 1. I would like to recognize and thank the team who gathered, analyzed and described the data and best practices in the document submitted to the ANCC to demonstrate how we met the criteria for redesignation and oversaw the site visit. Kristin Seidl, PhD, RN, Director of Quality and Safety, was the leader extraordinaire with the vision and skill required to produce the document and lead us to the finish. She was skillfully supported by Rachel Hercenberg, MS, Supervisor of Oncology Operations, and Tia Milburn, BA, Project Specialist. Carolyn Guinn, MS, RN, Magnet Program Director, Tia and Kristin planned and oversaw our site visit. Greg Raymond, MS, MBA, RN, Director of Nursing for Clinical Practice and Professional Development, NeuroCare and Behavioral Health, and Kimmith Jones, DNP, RN, CCNS, RN-BC, Director of Translation to Nursing Practice, were instrumental in a variety of functions. continued on page 11. Lisa Rowen, DNSc, RN, FAAN, Senior Vice President of Patient Care Services and Chief Nursing Officer; and Jeffrey A. Rivest, President and Chief Executive Officer The Dream Team Clinical Practice & Professional Development Kristin Seidl, PhD, RN Carolyn Guinn, MS, RN Rachel Hercenberg, MS Tia Milburn, BA Greg Raymond, MS, MBA, RN Maureen Archibald, MS, RGN, RMN, RN Erica Bergstein, MS Susan Carey, MS Michael Costello, MHA Chris Couchman, MS, RN Brandi Finch Kristy Gorman, MS, RN, OCN Carolyn Guinn, MS, RN Rebecca Holford, MSN, RN, CCRN, NREMT Donna Huffer, BSN, MA, RN, OCN Gerald Huffman, BS Kimmith Jones, DNP, RN, CCNS, RN-BC Luke Menefee, MPP Magnet Escorts Cameran Baker, BSN, RN Terry Biggins, BSN, RN Maria Cocoros, BSN, RN Nancy Corbitt, BSN, RN, OCN Tom Crusse, BSN, MS, RN, CEN Ivy Klein, MS, RN, CPN Cheryll Mack, BSN, MPA, RN Mindy Ralls, BS, RN Sue Ramzy, BSN, RN Stacey Trotman, MSN, RN, CMSRN Sarah Woodring, MSN, RN Tia Milburn, BA Traci Morris Allison Murter, MSN, RN Erin O’Grady, MS, RN, OCN, CNL Chandria Purnell Sara Reynolds, BA Lynnee Roane, MS, RN Cyndy Ronald, BA Gena Stanek, MS, RN, CNS-BC Rhonda Vaughan-Malhotra, BA Anthony Whitfield Patricia Wilson, BSN, MS, RN Patricia Woltz, PhD, RN Nelia Zhuravel, BS Magnet Champions Sheena Abraham, BSN, RN Taibat Nikki Alao, BSN, RN, CMSRN Josefina Armando, BSN, RN, OCN Noah Bennett, BSN, RN Blair Besche, BSN, RN Terri Biggins, BSN, RN Marla Brown, BSN, RN Dennis Brumbles, MSN, NE-BC, RN-BC Chris Byerly, BSN, RNC-NIC, Chair Ellaine Rose Camonayan, BSN, RN, RNC-MNN Theresa Card, BSN, RN Hydelin (Grace) Cerbo, BSN, RN Lora Cheek, RN, CNRN Courtney Chlebek, BSN, RN Jacqueline Christian, MSN, RN Lindsay Cuddeback, BSN, RN Karissa Driscoll, BSN, RN Terri Ellis, BSN, RN-BC Lovella Eugenio, BSN, RN, CNOR Zelda Falck, BSN, MS, RN Dara Graham, MS, RN Lindsey Gray, RN Darlene Gray-Silver, BSN, RN Carolyn, Guinn, MSN, RN Carmella “Penny” Happel, BSN, RN, OCN Juanita Hardy, RN Judy Hill, BSN, RN, ACRN Barbara Huber, RN, FCHN Christina Humphrey, BSN, RN Samantha Jacobs, MS, RN Treza James, MS, RN, NNP-BC, RNC Maureen Jones, RN Abby Keller, BSN, RN Sheila Lee, RN Sharon Lesser, RN Laura Lunz, BSN, RN, OCN Cheryll Mack, BSN, MPA, RN Carole Malinowski, BSN, RN, CPN Stacie Mann, RN, CCRN Kelly McCarthy, BSN, RN Tia Milburn, BA Todd Milliron, RN Jennifer Motley, BSN, RN, PCCN Mary Murray, MSN, RN Diana Novak, MS, RN, CCRN Francisca Nwugwo, MSN, RN Elaine Poole, RN Sue Ramzy, BSN, RN Barbara Redwood, RN, CNOR Megan Reio, BSN, RN Chona Rizarri, BSN, RN, PCCN Dale Rose, MSN, DHA, RN Chelsea Ruch, BSN, RN Maggie Ryan, BSN, RN Patricia Ryan, BSN, MS, RN Kristin Seidl, PhD, RN Crystal Siu, BSN, RN Megan Smith, BSN, RN Yvette Tan, BSN, RN Bridget Taylor, BSN, RN, CCRN Stacey Trotman, MSN, RN, CMSRN Stacey Uddeme, RN, CPEN Barbara Wahl, MA, RN Cathy Wilkes, RN, CCRN Kristin Wilks, BSN, RN, OCN news &views Magnet Re-Designation, continued from page 10. Our Magnet Champions, expertly led by Chris Byerly, BSN, RNC-NIC, focused on a local level to work with and educate their unit-based teams. The Champions, as well as the Magnet Communication Subgroup led by Stacey Trotman, MSN, RN, CMSRN, infused the preparation for and implementation of our site visit with enthusiasm, energy, and excitement â€“ they were spectacular leaders in our redesignation process. The Magnet Escorts set the tone for a positive, upbeat and energized site visit with the appraisers. Finally, we are fortunate to have a magnificent Clinical Practice and Professional Development team. This group is expert at doing anything and everything, no matter how small or large the challenge. The members of the CPPD team stepped up in their usual way, with grace, a can-do attitude, and skill. It is an honor and a privilege to work with a nursing team so dedicated to and passionate about their patients and profession. Iâ€™ve got Magnetude, and I know you do too! Are you submitting photos for use in News & Views? Tips for taking better pictures with your smartphone. 1. Skip the zoom. Images start to degrade as soon as you hit the zoom button. They can be cropped later. 2. Provide high-resolution images. The original image downloaded from your smartphone is a high-resolution jpeg. The best way to submit it to News & Views is to email the actual size image directly from your phone, or the uploaded jpeg from your computer. Sending your image in a Word document or texting it will greatly reduce the quality, making it unusable. Karen E. Doyle, MBA, MS, RN, NEA-BC; and Kristy Gorman, MS, RN, OCN Patricia Jefferson; Treza James, MS, RN, NNP-BC, RNC; and Brandi Finch 3. Remember to focus. It's so easy to just snap the picture without focusing because it looks great on the screen. But when that photo is going to be in print, it needs to be sharp. 4. Have your subject face the light. This prevents backlighting and faces that are in dark shadow. 5. Clean your camera lens. Pockets are not clean places. It's okay to wipe the lens with a tissue or a soft piece of clothing. 6. Use the flash selectively. In bright sunlight, the flash can help eliminate dark shadows. In low-light situations, try one shot with the flash and one without. Sometimes, no flash gives a better result. 11 12 Spring 2014 UMMC Nurses are Magnetized… Again! by Christine Byerly, BSN, RNC-NIC and Stacey Trotman, MSN, RN, CMSRN UMMC nurses waited patiently on May 14, 2014, at 4 pm to hear the results of our quest to receive Magnet designation for the second time from the American Nurses Credentialing Center (ANCC). Celebrating the good news! The call came from Deborah Zimmerman, DNP, RN, NEA-BC, FAAN, Chair of the Commission on Magnet Recognition to Lisa Rowen, DNSc, RN, FAAN, Senior Vice President for Patient Care Services and Chief Nursing Officer and an auditorium full of anxious nurses and colleagues. Those present included UMMC President and CEO Jeffrey R. Rivest and other senior leaders, Magnet program directors Kristin Seidl, PhD, RN, and Carolyn Guinn, MS, RN, and our Magnet Champions. Cheers erupted when we heard we were designated for the second time. The joyful noises turned into quiet tears of joy as Zimmerman spoke of our exemplary practice. Noteworthy were our areas of strength in nursing governance structure and a culture that encourages and supports nurses to seek advanced degrees and training. Nurses are empowered to play a crucial role in promoting and advancing quality patient care, sustaining a culture of safety, and a mind for inquiry. UMMC is one of only 7 percent of hospitals nationwide that hold this prestigious designation of excellence. The journey to achieving Magnet re-designation began four years ago – almost as soon as we were designated the first time. We captured years of exemplary nursing practices in the Magnet application for re-designation, which we submitted on August 1, 2013. Even prior to submission of the document, the Magnet Champion group, led by Christine Byerly, BSN, RNC-NIC, met monthly over the past several years to learn the new Magnet model, track nursesensitive quality indicators, discuss exemplary practice, and collect evidence for the document. The journey, however, did not end with our document submission. As we waited to hear whether our document proved us worthy of a site visit from the Commission on Magnet Recognition, Magnet Champions began putting plans in place. Champions immediately began working on the task at hand, including ways to showcase our unit examples of living excellence, prepare staff for bragging, and generate energy and enthusiasm with our infamous “I’ve Got Magnetude!” logo. Champions decided to create a portfolio for each of their units on display boards that highlighted their advances in clinical practice, quality and safety, certifications, performance improvement, evidence-based practice, and research. The Magnet Champions remained an integral part of the Magnet journey. The Magnet Communications Subgroup, led by Stacey Trotman, MSN, RN, CMSRN, reconvened in October of 2013 and began mapping out plans for unit rounding. With the Top 10 Questions in hand, pairs of Magnet Champions visited units to prepare staff for an anticipated site visit. Shortly after hearing we were granted a site visit scheduled for April 2-4, 2014, you may have seen the “Magnetrain” come though your unit to hand out “I’ve Got Magnetude!” buttons, flyers, and candy. Days leading up to the Magnet site visit, several nurses and Clinical Practice and Professional Development staff were selected and organized into teams to facilitate up-front and behind-the-scenes operations of the site visit. Nine nurses within the organization were selected to serve as escorts for the Magnet appraisers. The Advance Team served as cheerleaders to energize staff and ensure they were gathered and prepped minutes before the appraiser visited the unit. The Magnet Champions served as way-finders and facilitators for the transition of sessions with the appraisers. The command center staff served as the hotline and gatekeepers for flow and communication to ensure a seamless site visit. During the site visit, the excitement was so palpable that we were unsure how we were going to manage waiting until July to find out the results of our Magnet re-designation. Much to our surprise, we would not have to wait long, learning that our call would come on May 14, 2014. And… “We Did It, Again!” news &views Certification Corner An Inside Look Into the American Nurses Credentialing Center: Assuring a Valid, Reliable and Fair Certification Exam By Dennis Brumbles, MSN, BSN, NE-BC, RN-BC The Certification Committee has been advocating for specialty certification since its genesis, expounding the benefits of professional certification to increase patient care outcomes and to give the individual nurse a sense of increased professionalism and pride in practice. The benefits of certification have been well documented in the literature (Coleman et al., 2009, KendallGallagher & Blegen, 2009). Yet, despite these undeniable benefits of certification, some nurses are hesitant to sit for their specialty certification for fear that they may not pass. The American Nurses Credentialing Center (ANCC) uses volunteers to provide their expertise in advancing nursing practice. I have been fortunate to be a member of the content expert panel for psychiatric and mental health nursing for the past two years, and this has given me a unique insider’s look at how test integrity is established and maintained. Every certification exam contains a number of questions that do not count toward the final score, otherwise known as “test questions.” The results of these questions are analyzed by one of the ANCC’s psychometricians, a PhD in mathematics, who meets with the panel to review the scores from a new bank of questions based on the range of candidates who took the test. The panel is given the task of making test questions easier, harder or eliminating them altogether in the event it is deemed “unfixable.” The questions then undergo another round of testing and re-examination before being elevated to full “test question” status. It is a laborious process, but by doing so, the candidate is assured that the test has undergone both mathematical analysis and close professional scrutiny by a panel of practicing clinicians. The seven panelists from across the United States who met this past February at the American Nurses’ Association’s headquarters in Silver Spring, MD, had a total of two hundred and three years of nursing experience between them! The panel assures that the exam is fair by making sure that each correct answer can be referenced to a current, recognized nursing textbook. The ANCC publishes a study guide for each of their certification exams. These guides are invaluable in preparing the candidate for the exam. The content of the test is closely reflected in the study guide. I strongly recommend that anyone sitting for the exam obtain and prepare using the study guide. It will help you adequately prepare, boost your confidence, and act as a general refresher for your daily practice. Go in and take the test and prepare to continue your career as a certified nurse. Certification makes a difference! 2014 Certification Breakfast a Success By Dennis Brumbles, MSN, BSN, NE-BC, RN-BC The 2014 certification breakfast, held on March 19th, offered nurses across the organization a chance to get together, share fellowship and discuss the benefits of nursing certification. A poster with pictures from the certification breakfast was presented to the Magnet surveyors as evidence that the organization both believes in and supports UMMC nurses becoming certified. The Certification Committee wishes to thank UMMC for its support. References Coleman, E. A., Coon, S. K., Lockhart, K., Kennedy, R. L., Montgomery, R., Copeland, N., McNatt, P., Savell, S. & Stewart, C. (2009). Effect of certification in oncology nursing on nursing sensitive outcomes. Clinical Journal of Oncology Nursing, 13(2), 165-172. Kendall-Gallagher, D., & Blegen, M. A. (2009). Competence and certification of registered nurses and safety of patients in intensive care units. American Journal of Critical Care, 18(2), 106-113. Michelle Marcelo, BSN, RN-BC, and Joseph Raymond Agalabia, BSN, RN-BC 13 14 Spring 2014 AMBULATORY SERVICES Making the Transition: Care Coordination in a Resident’s Internal Medicine Clinic Karen Lyons, BSN, RN, CCHP, Nurse Manager, University Health Center (UHC); and Kaylee Barnes, BSN, RN, UHC Studies show that with care coordination assistance patients have better health outcomes and fewer hospital admissions (Ahmed, 2010; White, 2014). It is critical that patients get the right educational tools to be able to successfully manage their disease(s) in an ambulatory setting. Self-management education and health literacy are critical in helping these patients prevent or delay the complications of their disease(s). The ambulatory nurse is well-positioned to assist these patients to manage their disease(s) and help to ensure better overall health outcomes. The nurses of University Health Center (UHC) implemented the role of nurse navigators for patients identified as moderate to high risk in the internal medicine resident’s clinic in 2013. The nurse navigator collaborates with the medical team to develop a tailored care plan, set goals, coordinate care and educate the patient to improve selfmanagement of their health issues, ultimately leading to reduced hospital admissions and emergency room visits. Residents identify patients that need a more hands-on approach to their health care and will refer them to a nurse to be enrolled into the program. Referrals can be made by any provider, but also by staff who have identified a need during the course of providing care to the patient. Patients that qualify for a nurse navigator typically fall into categories three though six on the modified American Academy of Family Physicians (AAFP) Risk-Stratified Care Management and Coordination scale (AAFP, 2012). Typically, patients falling within categories three and four are in the program for 30 days. Those continued on page 15. Risk-Stratified Care Management and Coordination* Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Primary Prevention Primary Prevention Secondary Prevention Secondary Prevention Tertiary Prevention Catastrophic Prevention GOAL: To prevent onset of disease (Low Resource Use) GOAL: To prevent onset of disease (Low Resource Use) GOAL: To treat a disease and avoid serious complications (Moderate Resource Use) GOAL: To treat a disease and avoid serious complications (Moderate Resource Use) GOAL: Treat the late or final stages of a disease and minimize disability (High Resource Use) GOAL: May range from restoring health to only providing comfort care (Extremely High Resource Use) CARE PLAN SUGGESTIONS – Preventive screenings and immunizations – Patient education – Health risk assessment (annual) – Appropriate monitoring for warning signs CARE PLAN SUGGESTIONS – Preventive screenings and immunizations – Patient education – Health risk assessment (annual) – Appropriate monitoring for warning signs CARE PLAN SUGGESTIONS – Preventive screenings and immunizations – Patient education and engagement – Health risk assessment (semi-annual) – Appropriate monitoring for warning signs – Interventions for unhealthy lifestyle/habits – Links to community resources to enhance patient education, selfmanagement skills, or special facilities CARE PLAN SUGGESTIONS – Preventive screenings and immunizations – Patient education and engagement – Health risk assessment (semi-annual) – Appropriate monitoring for warning signs – Interventions for unhealthy lifestyle/habits – Links to community resources to enhance patient education, selfmanagement skills, or special facilities CARE PLAN SUGGESTIONS – Preventive screenings and immunizations – Patient education and engagement – Health risk assessment (quarterly) – Appropriate monitoring for warning signs – Interventions for unhealthy lifestyle/habits – Links to community resources to enhance patient education, selfmanagement skills, or special facilities CARE PLAN SUGGESTIONS – Hospitalization – Rehabilitation – Long-term care – Hospice/palliative care TEAM/PLANNED CARE – Home self-monitoring – Links to the medical neighborhood for care management, coordination of care, treatments, communication, and exchange of information with other providers and health care settings. TEAM/PLANNED CARE – Home self-monitoring – Links to the medical neighborhood for care management, coordination of care, treatments, communication, and exchange of information with other providers and health care settings – Health coach – Referrals, as appropriate TEAM/PLANNED CARE – Home self-monitoring – Links to the medical neighborhood for coordination of care, treatments, communication, and exchange of information with other providers and health care settings – Health coach/ personalized care plan/ management and resources – Referrals, as appropriate – Home health TEAM/PLANNED CARE – Support groups – Links to the medical neighborhood for coordination of care, treatments, communication, and exchange of information with other providers and health care settings – Health coach/care management – Referrals, as appropriate – Home health – Personalized intensive care plan/management and resources *Chart and info modified from the “Risk-Stratified Care Management and Coordination” by the American Academy of Family Physicians news &views Ambulatory Services, continued from page 14. Navigator Workflow falling into categories five and six will typically require assistance for 60 days or more. Within one to two business days from a referral, a nurse contacts the patient and will develop a care plan based on referral and information from the patient. The program is explained to the patient and goals are developed based on the patientâ€™s personal strengths and weaknesses in managing their own health. Within the first 30 days of the program, the nurse contacts the patient weekly, or more as needed. Some examples of care coordination that are utilized include: medication pill box fills, appointment reminders, and diabetic teaching. Evaluation of the patient is performed at day 31 by the nurse and physician and the assessment of the patientâ€™s goals progression is evaluated to determine if further coordination is warranted. The evaluation will determine one of the three distinct courses of management for a patient: discharge from the program, continuation with the program for 30 more days, or movement to the UHC long-term primary care nurse program. All of these scenarios are discussed and the patient is informed of the final decision. Currently, eight patients have been enrolled in the program and none have been readmitted or had additional emergency room visits. After learning the basic skills to manage their needs at home, patients are able to develop their own sense of self-confidence around their health/wellness. Moreover, they are able to exercise autonomy in their care, demonstrating success of the program in this early stage of implementation. References Ahmed, O., & Rak, D. (2010). Hospital Readmission Among Participants in a Transitional Case Management Program. The American Journal of Managed Care, 16, 778-783. American Academy of Family Physicians (2012). Risk-stratified care management and coordination. From www.aafp.org/documents/AAFP/documents/practice_ management/pcmh/initiatives/RSCM.pdf. Retrieved June 16, 2014. White, B., Carey, P., Flynn, J., Marino, M., & Fields, S. (2014). Reducing hospital readmissions through primary care practice transformation. The Journal of Family Practice, 63, 67-74. 15 16 Spring 2014 The following is a reprint of an article, written by a family member of a former patient at UMMC, and first published in "The County Times" in St. Mary's County, Maryland on March 20, 2014. Helping Hands Laura Joyce, firstname.lastname@example.org, The County Times, St. Mary’s County, Maryland The long and difficult journey my family has been on with my stepmom Luann, a journey of illness and treatment, hope and despair, and more recently, coming to accept the inevitable came to an end when she slipped away on Friday morning. We knew her death was imminent by last week: she was so tiny toward the end, so exhausted from fighting both the cancer and the chemo that we’d hoped might save her in a more optimistic time. Earlier that morning, she and my father exchanged “I love yous,” as they did every morning, and not long after, she quietly passed from here to there. You make a temporary family, of sorts, forming connections with strangers and close bonds with acquaintances, when you go through something like this. This is especially true in the intense final days, as you negotiate your way through so much that is unknown. Life is reduced to a small room and the background murmurings of doctors and nurses and the artificial light that makes everyone look worn out and a little frightened, except you really are – worn out and frightened – so who’s to say if it’s the light, or the loss that’s coming at you like a freight train? After Lu’s death, word spread quickly through the unit and out into the huge, impersonal halls of the University of Maryland Medical Center, filtering down elevator shafts and stairwells and making the place seem small and familiar. When my father and I walked through the hospital later that morning, we were approached time after time by nurses, doctors, schedulers and cafeteria workers and valet parking attendants, some tearful and some more contained, but all offering genuine sorrow, and a hug or a touch on the arm, personal condolences and memories of Lu that had formed in such a short time. Dad and Lu were wellliked there, which doesn’t surprise me: their patience and humor made them memorable in a place where neither quality is often in attendance, for understandable reasons. It was their devotion to each other that really did it, though: my father’s tender, aroundthe-clock care for his wife of 33 years was at once so beautiful and so heartbreaking that you couldn’t look away. The genuineness and open hearts of the people that traveled through this difficult, sad last week helped my father immeasurably: I was only there briefly, but I could see that grief is the most natural thing in the world on the (9th) floor, and that creates a place where families are safe whether loss comes hurtling toward you or creeps in quietly. Either way, it up-ends life as you know it, and the team that surrounds families there faces down that chaos of death and makes it just a little bit less overwhelming. Over the past year, Lu received superb care, but when there was nothing more that could be done medically, the people from the (9th) floor turned their efforts toward helping my father say goodbye. And on Friday, after losing the woman he had loved for so much of his life, they were still there for my father, an unobtrusive and unmistakable cradle of support, somehow both gentle and strong as steel. I can’t imagine the courage it takes to do this work day after day, to see families in their saddest moments, as grief descends, but I saw the courage in action, and I admire it deeply. In the spaces around my grief for my father’s loss, for my own loss, for my family’s loss, I am filled with admiration for the people who step into the storm with others, offering the shelter of empathy. The doctors and nurses and hospice workers and others who surrounded my father and stepmother, open-hearted when they could so easily have chosen to face grief from the safety of clinical distance, are heroes to me: I imagine them reaching out to help, as our changed family sets out on this new road together, learning how to carry our grief; they are lifting the sharp, heavy pieces of the heartbreak from my father’s full hands, making the journey ahead just a little bit lighter, and my gratitude is endless. Acute Care Nurse Practitioner Residency Program, continued from page 3. We expected that the NP residency would ease the practice transition, improve NP retention, develop evidence-based practice to assure beginning level critical care APN competency upon successful completion of this intensive nine-month program. Our initial goals have been met, and likely succeeded as there has been overwhelming request by practicing APPs to attend the programs. Interdisciplinary interest and participation has been wonderful. Our MD colleagues have reported satisfaction with the graduates of each cohort, each of whom is credentialed to practice in each critical care area at the completion of the program. Ultimately, our patients and their families benefit from this competent and skilled APP work force. References American Association of Colleges of Nursing. Adult-Gerontology Acute Care Nurse Practitioner Competencies. (2014). Retrieved from http://www.aacn.nche.edu/ geriatric-nursing/adult-gero-acnp-competencies.pdf. Accreditation Council for Graduate Medical Education. (2009). Retrieved from https://www.acgme.org/acgmeweb/Portals/0/PDFs/commonguide/IVA5c_ EducationalProgram_ACGMECompetencies_PBLI_Explanation.pdf. American Nurses Credentialing Center. (2014). Practice Transition Accreditation Program. Retrieved from http://www.nursecredentialing.org/Accreditation/ PracticeTransition. Health Resources Services Administration. (2013). Nurse Education, Practice, Quality and Retention. Retrieved from http://bhpr.hrsa.gov/nursing/grants/nepqr.html Institutes of Medicine of the National Academies. The Future of Nursing Leading Change Advancing Health Report 2010. Retrieved from http://www.iom.edu/ Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/ReportBrief.aspx?page=2. Kleinpell, R., Ely, E., Grabndort, R. (2008). Nurse Practitioners and physician assistants in the intensive care unit: An evidence-based review. Critical Care Medicine. 36, 2888-2897. Lammers, R., Davenport, M., Korley, F., Griswold-Theodroson, S., Fitch,M., Narang, A., Evans, L., Gross, A., Rodríguez, E., Dodge, K., Hamann, C, Robey, W. (2008). Teaching and Assessing Procedural Skills Using Simulation: Metrics and Methodology. Academic Emergency Medicine. 15, 1079-1087. Newhouse, R., Stanik-Hutt, J., White, K., Johangten, M., Bass, E., Zangaro, G., Wilson, R., Fountain, L., Steinwachs, D., Heindel, L., Weiner, J. (2011). Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review. Nursing Economics, 29, 1-21. Rauch, K. (2013). Are Residencies the Future of Nurse Practitioner Training? Retrieved from http://scienceofcaring.ucsf.edu/future-nursing/are-residencies-future-nursepractitioner-training. University Health Consortium: Mission Statement. 2013. Retrieved from https://www. uhc.edu/12443.htm. news &views Clinical Education Council (CEC): When Change Impacts Patient Care Delivery Maureen Archibald, MS, RGN, RMN, RN, Clinical Practice and Professional Development New products, policy changes, and changes in practice from each department have the potential to impact the delivery of safe and effective patient care. To ensure that these changes are rolled out in a time sensitive and inclusive manner, the Clinical Education Council (CEC) is here to help! Who are we? The CEC is a multidisciplinary group that provides consultation, support, and facilitation for any and all changes requiring an educational component, with the potential to impact the safe and effective delivery of patient care. The council has several permanent subgroups for initial education and ongoing education, including the Graduate Nurse Advisory Council and the Code Blue Committee. The council also convenes ad hoc sub groups to assist with other education events and is a close partner with the Clinical Practice Council (CPC). What can we do for you? The CEC can provide an assessment of impact, identify structure, timelines, and supportive frameworks that ensure your proposed change meets with the right audiences and is embraced quickly into the safe and effective delivery of patient care. What can you do? Contact the CEC leadership as soon as you have a concept, change in practice/policy/procedure, identified educational need, new drug or product that could potentially or will impact patient care. We will assess with you the touch points for the information and help structure the most effective platform for your message. Timelines: ◗◗ Educational event support: Email CEC leaders two months in advance to meet with them and get on the agenda. ◗◗ Ongoing Education Topic: Must be complete and ready for distribution by January 1 for the spring education marathon and August 1 for the fall education marathon. Representatives from all departments are welcome to join the group. The more departments represented, the more effective we can be in delivering safe effective care to all our customers. The CEC meets on the third Monday of each month from 8:30-10:30 AM in the Weinberg third floor round room. Contacts Chair: Melanie Matthews, BSN, RN, CCRN Manager, Maryland ExpressCare email@example.com Chair Elect: Sandra Lovelace, BSN, RN CCRN-CSC Clinical Nurse Educator, Cardiac Surgery Intensive Care Unit firstname.lastname@example.org CNS Support: Karen McQuillan, MS, RN, CCRN, CNRN Clinical Nurse Specialist R Adams Cowley Shock Trauma Center email@example.com CPPD Facilitator: Maureen Archibald, MS, RGN, RMN, RN Lead Clinical Education Specialist Clinical Practice and Professional Development firstname.lastname@example.org Hand Hygiene Practices, continued from page 8. in this initiative was overwhelmingly positive. To get providers engaged, the team reached out to the STC Nurse Practitioner (NP) team, shared the HH initiative and formed a partnership in coaching colleagues in HH practices. The NPs and physicians were observed in rounds providing gentle reminders to their colleagues. We also engaged other disciplines such as rehabilitation services, environmental services, and food and hospitality services. At the start of each shift, the charge nurse was responsible for distributing the TST audit sheets. It was not uncommon to see the unit secretary, unit support aide or the patient care assistant distributing the audit sheets at the beginning of the shift. Over a period of three months, coaches were responsible for documenting observations of the interdisciplinary team members’ compliance with HH. A few key barriers to HH compliance included gloving without performing HH, ineffective placement of hand sanitizer dispensers, improper use of gown/gloves in isolation areas, distractions (i.e., rounds, admission, discharge), and frequency of entry and exit. In addition to tracking the non-compliant occurrences, we were able to identify and trend the compliance/non-compliance by department. When non-compliance was observed, staff members were encouraged to clearly communicate the HH expectations and to provide ongoing coaching and education. Over the course of ten months, HH compliance improved from 93% to 100%. This improved compliance of consistently meeting or exceeding the UMMC HH goal has been sustained for more than a year, surpassing the goal eleven of those twelve months. Although the TST project has been completed, the MTIMC 6 staff has created a culture that fosters clinical excellence as evidenced by consistently meeting and most often exceeding the medical center’s HH goal. References Centers for Disease Control and Prevention. CDC at work: Preventing healthcare associated infections. Retrieved from http://www.cdc.gov/washington/~cdcatWork/ pdf/infections.pdf Center for Disease Control and Prevention. 2014. Hand hygiene basics. Retreived from http://www.cdc.gov/handhygiene/Basics.html Joint Commission Center for Transforming Healthcare. 2014. Targeted solutions tool. Retrieved from http://www.centerfortransforminghealthcare.org/tst.aspx 17 18 Spring 2014 2013 Nurses Week 2014 P R I V I L E G E D TO C A R E , PASS I O N FO R E XC E L L E N C E Kick-off Event— Trends in Nursing Practice Conference 2014 – Integrative Care "Creating an Environment of Wellness for the Patient and the Healthcare Professional" The conference offered healthcare professionals, students, and faculty from various disciplines the opportunity to be introduced to integrative therapies for all aspects of wellness and health promotion. Live demonstrations and participation in yoga, Reiki, and zumba allowed participants to experience how to be refreshed and to translate that care to their patients. Amy Herman, JD, MA, delivered a very dynamic keynote address on the art of perception in nursing. Support Staff Salute Day and Team Celebrations Staff from Clinical Practice and Professional Development Individual units celebrated and recognized their support staff in various ways, including hosting breakfasts and lunches, and providing beautiful flower arrangements. Nursing Staff and Nursing Support Breakfast Nursing Support Staff and Team Celebration May 5, 2014 Please take time to recognize the Support Staff on your unit during this special day Unit Based Celebration Ideas Over 1,200 nurses attended the nursing staff breakfast where they were served a variety of delicious offerings by senior nursing leadership. Nursing Excellence Awards Special Achievement and Living Excellence award recipients were recognized during a ceremony hosted by Senior Vice President and Chief Nursing Officer Lisa Rowen, DNSc, RN, FAAN. Award booklets are available in the Clinical Practice and Professional Development satellite office. —Thank You Cards—Balloons— Breakfast Party—Lunch Party—Photo Montage—Flowers—Unit Based Awards— Recognition Boards—Hospital Vendor Gift Cards—Write an article on your support staff in News & Views— Nursesbreakfast Week Tuesday, May 6th, 6:00 am – 9:00 am After Hours Dining Area All Nursing staff and Unit Support staff are invited menu includes: scrambled eggs french toast bacon turkey sausage hash browns mini muffins fruit Served by hospital and nursing leadership. Left to right: Barbara Bosah, BSN, RN; Bing Casal-Calingacion, BSN, RN; Juanita Hardy, RN; Nicole Anthony, BSN, RN, CCRN, CCTC; Rebekah Friedrich, BSN, RN, CCRN; and, Marla Bryant, BSN, RN news &views Left to right: Jane M. Kirschling, PhD, RN, FAAN; Megan C. Lynn, PhD, MBA, RN, FNE-A; and, Lisa Rowen, DNSc, RN, FAAN Candy Cart Rounding This was a nice surprise for our night shift nurses! Volunteer nurses took candy carts around to all our clinical units and passed out special treats. Nursing Grand Rounds Topic: Health Care is a Team Sport: Optimizing Hospital Teams Speaker: Marian Grant, DNP, CRNP, Assistant Professor, OSAH University of Maryland School of Nursing 4th Annual Community Health Fair Nurses and nurse practitioners from 34 patient care units at UMMC and our Midtown campus met with over 1,000 members of the community at Lexington Market. Blood pressure screenings, HIV support, diabetes nutritional support, stroke awareness and weight management were some of the services provided to the community. Several external agencies were also involved in the fair, including the Baltimore City Fire Department. Friday, May 9th 10:00 AM - 2:00 PM Lexington Market 400 W. Lexington Street Baltimore, MD 21201 Featuring: Blood Pressure Screenings Coffee Bar Nurses were treated to a continental breakfast served by pediatric and NICU nursing staff. Live Music FREE Educational Pamphlets and Giveaways Health Topics Include: HIV Prevention · Smoking Cessation · Healthy Eating · Sickle Cell Disease · Diabetes · Cardiovascular Health Community Healthcare Resources · Cholesterol Control · Women's Contraception · and many more... www.umm.edu If you had a professional photo taken prior to Nurses’ Week and would like a copy, please send an e-mail to email@example.com with the subject line: “Nurses’ Week Professional Photo Request.” Upon receipt, we will be happy to send one to you. Left: A display at the community health fair shows choices for healthier food selections. Right: UMMC staff meet with members of the community at the health fair at Lexington Market. 19 20 Spring 2014 PACU Receives CNO Award, continued from page 1. Team from PACU and STC PACU with Bea Hazzard, MS, RN, CPAN, Nurse Manager and collaborative. You expect that from any unit leadership, but the staff across the entirety of the PACU is one that practices that with each and every encounter.” Nursing staff members are truly exceptional in their versatility, depth, and breadth of competencies and bring-it-on spirit. When you walk through the PACU, you will see two seas of scrubs: blue on the general side and pink on the trauma side. While these groups function to support the patient care on the two sides, they also function as one large group that pulls together to cover each other’s patients, when necessary. Bea Hazzard, MS, RN, CPAN, is the manager of the PACU and said she is “proud of the way the group works together and celebrates as a large team.” This team cares for approximately 80 patients across both sides per day, on a 24/7 basis. Patients occupy 43 bays in total, with 12 bays designated to Trauma and 31 to the General Operating Rooms. As the primary site for ECTs, the isolation bays, in addition to all of the bays in the PACU, are multi-purpose. At the start of the day, 4 to 8 of the bays are used for pre-operative preparation and holding throughout the day, with rapid turnaround of patients, where Sara Hohl, BSN, RN, Clinical Nurse II nerve blocks and epidurals can be started to promote OR efficiency. Collecting data on the pre-op holding area work is underway, and the staff members are looking at numbers of patients, time spent in the holding area, first case start times and other measures. Two nurses arrive at 6 AM to open the pre-op holding area, and the work is a collaboration of the PACU, Ambulatory Surgery Center Unit, and the Operating Room (OR) teams. Anesthesia providers appreciate the pre-op holding area as a safe place for patients awaiting surgical procedures. The patients are cared for by nurses who are responsible for ensuring all pre-op documentation is complete and the patient is being assessed in a controlled environment in a PACU bay, rather than waiting outside of an OR. The team’s “commitment to patient care is obvious through their willingness to spearhead new workflows beyond post-anesthesia recovery,” said Margie Goralski Stickles, MSN, MBA, RN, CCRN, Director of Nursing for Perioperative and Procedural Services. The PACU serves as the Medical Center’s area for daily and even minute-to-minute temporary bed expansion. Depending upon patient volume, the Trauma side may be used to care for Trauma Resuscitation overflow. Both sides board patients every night. PACU patient boarding is always a challenge at academic medical centers because we don’t have the luxury of a fixed, static OR schedule. We have post-operative patients who may need to return urgently to the OR from inpatient units; patients who are brought directly to the OR from the Trauma Resuscitation Unit, Critical Care Resuscitation Unit, and the Emergency Department; and an expanding transplant patient population that requires flexibility for continued on page 21. unplanned organ donation. Kristen Rouse, BSN, RN, Senior Clinical Nurse I and Bea Hazzard, MS, RN, CPAN, Nurse Manager with their Magnet story board. news &views PACU Receives CNO Award, continued from page 20. The PACU has boarders almost every night and the charge nurses do a good job spreading them across many nurses’ assignments. With charge nurses advocating for their patients to be moved to an inpatient unit as soon as possible, most boarders stay in the PACU for less than 24 hours. Occasionally, when the Medical Center does not have one extra bed, patients may need to stay in the PACU for more than 24 hours. In these cases, the PACU nurses coordinate “The post-anesthesia care unit (PACU) has continued to demonstrate the level of excellence and quality improvement that all units should strive for. Furthermore, many of the members have initiated policies and protocols to improve the care of postoperative patients. The entire team, including the trauma and general operating room staff, and their leaders, deliver and aspire to provide the highest quality of care. I am proud to work with all of them and congratulate them on this well-deserved award.” Caron Hong, M.D., M.Sc Assistant Professor, Medical Director of the Post-Anesthesia Care Unit (PACU), Department of Anesthesiology and Critical Care Medicine, University of Maryland School of Medicine, The Shock Trauma and Anesthesiology Research – Organized Research Center (STAR-ORC) the patient’s care in the same way inpatient nurses coordinate care, integrating multidisciplinary team members in the patient care requirements. Basically, the PACU staff members arrive to work and are up for anything. It may be prepping patients for surgical procedures; or providing perianesthesia care in the main PACU or satellite areas; or boarding ICU, IMC, and acute patients; or caring for adults, pediatric – did I mention they are PALS certified? – or ECT patients; or even discharging patients. And through the course of a 24-hour period, this type of diversity and turnover of about 80 patients can be exhausting for staff members. PACU nurses are leaders in studying fatigue in the profession. There is great pride in the fatigue research activities of the PACU team. “Here is a Magnet moment for you,” said Margie Stickles: Four nurses on the staff co-authored a paper that won the 2014 Mary Hanna Memorial Journalism Award. This award is given by the Journal of PeriAnesthesia Nursing, the official journal of the American Society of PeriAnesthesia Nurses, for journalistic style, originality, clarity of expression, relevance of content to the specialty, and overall contribution to the collection of published nursing knowledge. The nurse authors, including Bea Hazzard, are; Trisha Klein, RN, senior clinical nurse I; Brittany Russell, RN, CPAN, clinical nurse II; Patricia Walkowiak, BSN, RN, clinical nurse II; and colleagues Karen Johnson, PhD, RN, CCRN, and Dzifa Dordunoo, MSN, RN, CCRP, a doctoral student at the University of Maryland School of Nursing. The scholarly paper, “Work and Nonwork-Related Factors Associated with PACU Nurses’ Fatigue,” demonstrated that despite acute fatigue scores, intershift fatigue scores reflected recovery, and chronic fatigue scores were low. Bea explained, “the Medical Center’s PACU nurses have developed successful fatigue-reduction strategies prior to the study, which may account for the results. They include sufficient time between admissions, a culture of peer support and teamwork, a charge nurse out-of-the-numbers to coordinate the high volume of admissions, ensuring all nurses get at least one break during their shift, use of a flex shift nurse to prevent shift overruns, and reduction of the number of three consecutive 12-hour shifts.” Planning another study in the PACU, the nurses plan to conduct a randomized controlled trial to study the effectiveness and utilization of QueaseEase as an adjunct to usual antiemetic management of postoperative nausea and vomiting. The study will include inpatient and outpatient surgical patients from two hospital sites. At the Medical Center, the patients from the trauma and general sides of the PACU and the 7N PACU will be included. A proposal is being drafted for IRB review. Collaborating with orthopaedic surgeons in the Trauma Center, the PACU nursing staff on the trauma side are currently helping to facilitate several studies performed by our orthopaedic surgeons, such as the Oxygen Study. This aims to assess “the efficacy of supplemental perioperative oxygen in the prevention of surgical site infections.” It is a randomized controlled clinical trial in which the PACU nurse’s role is to provide supplemental oxygen to the patient based upon the level at which he/she is randomized. The study participants, 1,000 patients across 27 sites, have undergone plate and screw fixation of high-energy tibial plateau, pilon and calcaneous fractures. The nurse keeps the orthopaedic physicians unaware of the level of oxygen their patients are receiving and documents whether the study protocol was adhered to. If the patient’s treatment diverted from that indicated in the randomized instructions, this is documented by the nursing staff. continued on page 22. Above: Eric Smith, MD, Anesthesia Resident and Ashley Moran, BSN, RN, Clinical Nurse II Right: Alnie Snyder, Unit Secretary and Steve Anderson, BSN, RN, CNRN, Clinical Nurse II 21 22 Spring 2014 PACU Receives CNO Award, continued from page 21. In January and February, the PACU nursing staff participated in a survey to assess the relationship between compassion fatigue and unprofessional behavior. Trisha Klein is one of the research team members and a senior clinical nurse I in the PACU studying this important issue with colleagues, including Kathryn T. Von Rueden, MS, RN, ACNS-BC, FCCM. Nurses from the trauma side of the PACU were among the 523 Shock Trauma Center staff members surveyed for this study, which aims to assess how vicarious trauma relates to burnout and unprofessional behavior in a major trauma center. The team hopes to determine the staff’s perceptions of disruptive behavior, their compassion fatigue scores and whether staff reporting highcompassion fatigue also report high exposure to disruptive behavior. This study follows a previous one published in 2009 that measured compassion fatigue. The investigators hope to assess any differences in the overall scores that may have occurred since the first study, after interventions were enacted to attempt to mitigate the unfavorable effects of compassion fatigue on staff members at that time. Working on the trauma side of the PACU can offer emotional challenges for the staff members. They shared how well they know each other and can decompress together, processing events in a supportive and meaningful manner. Kristin Wojtowycz, BSN, RN, clinical nurse II, said, “Every day is different. We see everything from the routine to the unusual or extreme. In this PACU, the extraordinary can become typical. It’s not your average PACU.” When necessary, pastoral care chaplains are on site to help the staff through emotionally charged moments with patients and families experiencing acute trauma. The Integrative Therapy team regularly provides brief massages, Reiki and meditation for the staff, patients and families. A challenge noted by one of the nurses on the trauma side is “we need to treat every person respectfully, whether it is someone who committed a crime or someone’s 80 year old grandfather. Even Elshadie Birratu, RRT, Respiratory Therapist Julie Grahm, Patient Care Technician and Rob Rodriguez, BSN, RN, Clinical Nurse II the 80 year old who awakens from anesthesia may be unintentionally rude or violent. All patients are treated with dignity and respect here.” Recognizing the need for an excellent hand-off from the OR to the PACU, a process improvement was implemented. The team used the Plan, Do, Study, Adjust rapid-improvement process to address hand-offs. (See page 24 for details.) The team’s high standards have led most of them to seek certification by a national board. Twenty-one PACU nurses are certified in specialties and hold credentials, including CCRN, CPAN, CNRN, and CEN. Recognizing the desire of the nurses to study together for the certification exam, Bea Hazzard leads a study group with a nursing leader from Mercy Medical Center. This group meets over the course of 12 weeks and is open to nurses across the city, with five UMMC nurses participating. As you can see, the PACU team does it all! For their expansive knowledge base, depth of skill sets, advancement of the profession of nursing through research and publishing, improvement of patient outcomes through translational practice, lean work, unbelievable flexibility, spirit of positivity, cohesion, teamwork, collaboration, and compassion for their patients and each other, the PACU team has been selected to receive the CNO Award for Team Excellence. When asked what they feel most proud of, most of the PACU nurses mentioned their team. Kristen Rouse, BSN, RN, senior clinical nurse I, said, “Our team is great.” Christa Arndt, RN, clinical nurse II, said, “We share the same goals and concerns about patient care. We all want to manage the patients as best and safely as possible.” “When appropriate, we use our senses of humor to help our patients and us through challenging times,” added Debrahe Rowland, BSN, MFA, MS, RN, clinical nurse II. “I love this team,” said Bea. “They are so incredibly flexible and willing to take on challenges. They say to continued on page 23. me, ‘We’ve got this, Bea.’” news &views PACU Receives CNO Award, continued from page 22. “There is not a group of nurses more deserving of this award than the PACU staff. This unit exemplifies teamwork and excellence not only by their actions but also by their attitudes. They have been tolerant and patient with major construction, policy updates, and infrastructure changes (not to mention years with a single restroom!). During these changes patient care was never sacrificed. If anything, I believe the growing pains have brought the PACU staff closer together, and patients seem to have benefited by having the attention of a team rather than a single person. Each day nurses can be seen helping one another at the bedside, with paperwork, or with consultations to various services. They are a trustworthy group of care providers, and I cannot be happier for them to receive such an honor.” C.J. Bucci, MD Assistant Professor, Division of Trauma Anesthesiology, Department of Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine Mary Petrosino, RN, clinical nurse II, said, “Our manager pushes each of us to achieve more.” The nursing staff said Bea has done a wonderful job of letting us maintain our identities on both sides of the PACU, while creating a blended feel and team approach. Staff members from both sides of the PACU eat lunch together, socialize outside of work and problem solve together on a daily basis. Julie Busseau, BSN, RN, CPAN, senior clinical nurse I, said, “The thing I like best about the PACU is our co-workers. We have a great group of nurses who work hard and have fun while doing it.” Jean Ludwig, MS, RN, CCRN, senior clinical nurse I, adds, “just this morning, we were celebrating milestones and new nurses.” Evaliz Jimenez, RN, clinical nurse I, has just become a nurse. The team is thrilled she will be staying at the Medical Center and starting a new job in the Surgical Intermediate Care Unit. They spoke with tears in their eyes about what a wonderful team member Evaliz is and how they will miss her as she begins her new role. A patient care technician for the past seven years, Evaliz said, “when patients come out of the OR and speak Spanish, it is wonderful to speak with them.” The team provided many examples of how they care about each other and the patients, their adaptability and collaborative practice. When you hear the same themes repeatedly mentioned on rounds, you learn what is important to and valued by the team. For the team, the bottom line is patient care. Bea said “staff members are patient advocated. The PACU can be a kind of limbo area for patients and families, but the nursing team is always focused on ensuring the patient gets what he or she needs – the staff is constantly problem-solving.” Julie Busseau sums it up: “We don’t allow patients or their needs to be lost in the system. Each one is an individual with continued on page 24. individual care needs.” Melissa Smith, BSN, RN, Clinical Nurse II Ashley Moran, BSN, RN, Clinical Nurse II; Mary Petrosino, RN, Clinical Nurse II; and Brittney Usilton, BSN, RN, Clinical Nurse II 23 24 Spring 2014 PACU Receives CNO Award, continued from page 23. Plan, Do, Study, Adjust PROBLEM: Handoff from the Trauma OR to the trauma side of the PACU involves a multi-step process. The circulating OR nurse calls the PACU charge nurse to give an overview of the patient. This enables the charge nurse to assign the patient appropriately and the receiving PACU nurse to prepare for his/her admission and obtain the proper equipment and supplies based upon the patient’s surgery, brief history and condition. Once the patient arrives in the PACU, the anesthesia provider, usually a CRNA, provides a detailed bedside report. The PACU nurses noticed a trend toward the patient arriving to the PACU with a report from the OR nurse that was missing some information they deemed necessary, or at least extremely helpful. This meant that the PACU nurses often felt unprepared and spent time looking for equipment or supplies they didn’t realize they would need, delaying the OR team’s ability to leave the PACU. Often, this information was as simple as isolation status or the need for a cable to transduce arterial blood pressure, but it had the potential to negatively affect efficiency and safety. Sometimes patients even had to be re-assigned to a different bay on a moment’s notice. The charge nurses began to “pull” information from the OR nurses, and this sometimes led to frustration on both ends. MODEL FOR IMPROVEMENT What are we trying to accomplish? How will know if a change is an improvement? What changes can we make that will result in an improvement? ADJUST PLAN STUDY DO PLAN: A small team of OR and PACU nurses, spearheaded by Trisha Klein, RN, senior clinical nurse I, PACU, met to discuss this issue and developed a tool to facilitate report. It developed into a list of information the PACU nurses expected to have before the patient arrived in the PACU. The OR nurses agreed that this was information they could provide in their report. DO: The tool, typed on a small sheet of paper, now hangs near the phone in each OR to serve as a prompt for reporting to the PACU nurses. This simple tool provided clarity to all the OR nurses about the information the PACU expected to receive and they could gather this information before calling the PACU with report. The PACU nurses found themselves more satisfied with the reports they received and spent less time on the phone asking questions and waiting for the answers. Arriving in the PACU following a report with necessary elements, the patient received the undivided attention from the receiving nurse, who could focus on the patient’s assessment and needs rather than locating equipment/supplies at a moment’s notice. In addition, bedside report between a CRNA and/or anesthesiologist and PACU nurse includes some of the information provided by the OR nurse to the PACU nurse in the telephone report, but also includes the anesthetic course in more detail. While this report was typically thorough, it was somewhat providerdependent. In an effort to standardize anesthesia-provider information related to the PACU nurses, Linda Goetz, MHS, CRNA, director of the nurse anesthetists, provided a badge card for the CRNA staff listing the information most valuable during handoff to the PACU nurses. STUDY: When the time came for the OR/PACU expansion, Trisha worked with Phyllis Napfel, RN, senior clinical nurse I in the OR, to be sure that all the new staff were aware of and able to use the report tool. As the perioperative department has expanded and large numbers of staff were oriented en masse, this simple tool served to make sure everyone was sharing information consistently, enhancing efficiency and safety even if it was a nurse’s first time giving report. ADJUST: During a meeting of the OR Handoff Task Force (developed to identify areas for improvement and action plans), PACU nurses proposed a few additional fields they would appreciate more consistently hearing about from the CRNAs. This information was then added to the badge cards and they were redistributed to the CRNAs. The interdisciplinary team OR Handoff Task Force included representatives from both sides of the PACU, leadership, anesthesiologists, CRNAs, and a clinical nurse specialist. The revised card used by the CRNAs and anesthesiologists now includes the following information: HAND-OFF INFORMATION ◗◗ Patient name ◗◗ MRN ◗◗ Age ◗◗ Weight ◗◗ Allergies ◗◗ Surgeon ◗◗ Attending anesthesiologist ◗◗ Type of anesthesia administered ◗◗ Difficult airway (y/n) ◗◗ Airway type (ETT, LMA) ◗◗ Reversal of neuromuscular blocker (y/n) ◗◗ Opioid & analgesic totals ◗◗ Antibiotic & time of administration ◗◗ Additional medications ◗◗ Intraoperative fluid balances ◗◗ IV access & invasive lines ◗◗ Recent lab news &views Hearing Loss and Deafness By Emily Mudrick, BSN, RN, PCCN Imagine yourself surrounded by spanish speakers when you are beginning to learn the language. You focus on trying to understand the conversation: Catching bits and pieces of words or phrases you comprehend, integrating those bits on the fly into sentence fragments, and guessing to fill in the gaps. After you’ve finally figured out what they’re saying, the topic has already changed and the process starts all over again, making actual participation quite challenging. This is an everyday reality for a hard of hearing person when it comes to communicating in a world primarily comprised of hearing people. A hard of hearing person experiences difficulty passively engaging in conversation; he or she has to actively listen to be involved. Active listening requires that the hard of hearing person determine who is talking, then follow mouths, read lips, process the sounds, etc. If there is conversation going on off to the side or behind us, we can likely hear sounds but not understand the words or even be aware that we are being spoken to. Only when we are actively listening and paying full attention to the words being spoken to us can we understand the conversation. My name is Emily Mudrick and I am a nurse who works in the Shock Trauma PACU. I have a moderately severe to severe congenital hearing loss and I wear bilateral hearing aids. To put it in perspective, if I take my hearing aids out, I can’t hear people talking, alarms chiming, call bells ringing, etc. While this option is great for sleeping in, it adds a degree of complexity to daily communication tasks. Having lived with this hearing loss for all of my life, I have overcome obstacles and learned how to strive and thrive in the hearing world. As with many people in the hard of hearing community, I’ve found that a combination of active listening skills on my part and some courtesies extended by those around me can have an amazing effect on the quality of our conversation. I am writing this article to help increase awareness of simple techniques for effectively communicating with someone who has a hearing loss, whether it is a co-worker or patient. My goal is to provide you with some culturally sensitive insight and tips so that your next encounter with a hard of hearing person will be a comfortable and smooth one. As you read through these techniques, you might even find that several of them can be applied to all conversations you hold with anyone. First and foremost, know that hearing aids don’t actually correct hearing to the same degree that eyeglasses correct vision. Hearing aids simply aid the person’s residual hearing and amplify sounds. With that being said, every hard of hearing person is unique depending on their type of hearing loss, the severity of that loss, and the kind of aid they use, whether a hearing aid or cochlear implant. There are multiple variables which dictate how well a hard of hearing person can hear even with the best technology that is offered today. Regardless of any of the factors, like most people, hard of hearing people benefit from face-to-face conversation. Because passively listening is challenging, eye contact is crucial and allows the person to realize that you are talking specifically to them. If you haven’t made eye contact yet, a good way to gain his/her attention is by calling his/her name, waving, or simply tapping on the shoulder. It provides an opportunity for the person to get into an “active listening mode,” thereby leading to an effective conversation. Oftentimes, people will think I am ignoring them if I don’t answer, but that isn’t the case; I simply did not realize you were directing conversation towards me. I promise you, we are not that mean! Additionally, try not to walk away and talk at the same time. Once eye contact is lost, it makes understanding what’s being said a lot more difficult. Keeping your mouth clear and uncovered is important as well. Lip reading is a common active listening technique employed by hard of hearing people and, as you might suspect, an uncovered mouth is much easier to lip read. As far as I know, clearly enunciating words benefits everyone and it definitely is helpful for people with hearing losses. When talking, speak slowly and distinctly; but, at the same time, yelling and over-pronouncing are unnecessary. Exaggeration and overemphasis of words distort lip movements, making speech reading harder. Articulate each word without force or tension while being conscientious not to mumble. Enunciate at a clear and normal rate and it’ll save you the time and effort of having to repeat yourself, leading to an effective conversation. Group settings are definitely a challenge for the hard of hearing. Even though we actively listen, ping-pong conversation becomes very hard to follow and many times we are not sure when speakers have finished. If you happen to be in a group where someone has a hearing loss, recognize that and try to keep the pace of conversation slower to allow them a chance to follow each speaker. If a hard of hearing person asks “what?” or informs you they didn’t hear you, just simply repeat yourself as he/she just didn’t understand the words you said. Usually, after repetition, he/she will understand the content and conversation can proceed. If you find that you’re repeating yourself several times, rewording your phrase without losing the original meaning of your statement also helps. Finally, answers like “never mind” or “it wasn’t important” after being asked to repeat yourself are more hurtful than not. We would like to be included in conversation and words like those don’t give us the chance to be involved. A little extra time and patience goes a long way in ensuring fluent dialogue. I would like to thank you for your time in reading this article. Hopefully I have provided some quality information that will benefit your next encounter with a hard of hearing person, whether it would be a fellow colleague or a patient. Being culturally sensitive and aware will prove to be beneficial for all persons involved. If you have any questions, please feel free to email me (firstname.lastname@example.org) and I will gladly respond! I am very open and proud of who I am with my hearing loss, and am willing to help out in any way. 25 26 Spring 2014 NURSE RESEARCH Call for Applications for Joint UMSON and UMMC Research Proposals! We are pleased to announce a call for joint research proposals examining nurse-sensitive outcomes in the hospital or community from a team comprised of at least one University of Maryland School of Nursing (UMSON) faculty member and one University of Maryland Medical Center (UMMC) nurse. Although any scientifically sound proposal will be considered, proposals examining nurse-sensitive outcomes in the hospital or community will be given highest priority. Nurse-sensitive outcomes are defined as the patient outcomes sensitive to nursing intervention. The proposals should follow the NIH R21 grant format. Proposals should be sent to Khristine Bozylinski-Bulos in the SON Office of Research at email@example.com. The deadline for receipt of proposals will be 4:00 PM, August 1, 2014, with funding by September 1, 2014. Proposals will be reviewed by a panel of UMSON and UMMC nurse scientists. IRB or IACUC approval for the proposed projects will be required prior to release of funds. For those who may be new to grant writing, we are available to help. We anticipate that we will be able to fund two proposals for up to $15,000 each. For more information, including requests for application forms, please contact Patricia Woltz, PhD, RN, Director, Nursing Research, UMMC (firstname.lastname@example.org) or Susan Dorsey, PhD, RN, FAAN, Associate Professor and Associate Dean for Research, UMSON. Understanding the Second Victim: A Qualitative Approach Ingrid Connerney, DrPH, RN, Senior Director, Quality, Safety, and Clinical Effectiveness, University of Maryland Medical Center; Badia Faddoul, DNP, RN, Clinical Practice Coordinator, University of Maryland Medical Center; and Lyn S. Murphy, PhD, MS, MBA, RN, Associate Professor, University of Maryland School of Nursing Introduction In 1999, the Institute of Medicine (IOM) estimated that 98,000 people died each year from preventable medical errors, (IOM, 1999). Despite best efforts to reduce errors, or more commonly known today as adverse patient events, a recent study released by the Office of the Inspector General, US Department of Health and Human Services (2010) posited that about 180,000 Medicare beneficiaries continue to die each year from adverse patient events and 44 percent of the events were likely preventable. Moreover, about one in seven Medicare patients experienced a serious adverse patient event and that an additional one in seven experienced a “less serious adverse event” (Clancy, 2012). Thus, while our healthcare system has had many successes in reducing adverse patient events, these events continue to be a cause for concern. While these numbers are deeply disturbing, what goes unrecognized is the “countless number of healthcare professionals” attached to each of these events (Scott, Hirschinger, Cox, McCoig, Brandt, and Hall, 2009, p. 325). Specifically, these events involve an individual who provides services such as physicians, nurses, allied health clinicians, support personnel, students and volunteers to patients. The emotional response to adverse patient events has been described in the literature as a “second victim” phenomenon or syndrome. Specifically, second victims are: Healthcare providers who are involved in an unanticipated adverse patient event, in a medical error, and/or a patientrelated injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base (Scott, et al, 2009, p. 326). continued on page 27. news &views Understanding the Second Victim, continued from page 26. A recent online survey conducted at University of Maryland Medical Center (UMMC) as part of a performance improvement project demonstrated the prevalence of second victims among UMMC healthcare professionals. Of the 410 healthcare workers who participated in the online survey, almost 40 percent indicated that they are second victims healthcare workers who have been directly or indirectly involved in an adverse patient event. Of those involved in an adverse event, 36 percent indicated that they were negatively impacted. Additionally, 38 percent of responders indicated that there was inadequate support following an adverse event and 30 percent indicated that there is a “blame culture” at UMMC. As a result of this online survey, the purpose of this study was to define the “second victim” experience among nurses practicing at UMMC, and to create effective support strategies that will enable nurses who experience an adverse patient event to engage in a healthy recovery in order to function at an optimal level. Methods and Results Following IRB approval from the University of Maryland, twelve nurses from UMMC were recruited to participate in a series of three intense one-on-one interviews to discuss their experiences as a "second victim" and how their experience can be used to create creative strategies. On average, the nurses were 34.2 years of age with 9.16 years of nursing experience. Twelve nurses completed the first interview and nine nurses completed the second and third interview. Using Streubert’s (1991) methodology for analyzing qualitative research, the following themes were identified from the interviews: A. Experienced an Adverse Event a. The Actual Moment: The nurse recognizes he/she made an error and there is a moment of overwhelming doom. b. A Few Minutes Later: The focus becomes the safety of the patient. The nurse’s response is mechanical in nature. c. After the Event: The issue is not discussed openly among the unit or organization. d. The Aftermath: The nurse questions his/her future as a nurse. B. Finding Forgiveness: Nurses, in general, do not accept or forgive those who have made mistakes. This inhibits the individual from forgiving himself/herself. C. Moving Forward: The event or error is not resolved with the individual, thus the nurse may carry the error with him/her, and as a result, the nurse begins to question his/her ability to function to his/her optimal level. Discussion This study demonstrates the need for more discussion surrounding how UMMC handles adverse patient events with regard to the individual nurse that may be involved in the event. The focus needs to be centered on not only providing support for the individual, but providing support for the unit as a whole. The leadership team, Staff Nurse Council and the Nurse Managers Council will play an active role in creating strategies to address this important issue. References Clancy, C.M. (2012). Alleviating “Second Victim” syndrome: How we should handle patient harm. Journal of Nursing Care Quality, 27 (1), 1 – 5. National Institute of Medicine. (1999). To err is human: Building a safer healthcare system. Washington, DC: National Academy Press. Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Brandt, J., & Hall, L.W. (2009). The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Quality & Safety in Health Care, 18 (5), 325-330. Streubert, H.J. (1991). Phenomenological research as a theoretic initiative in community health nursing. Public Health Nursing, 8(2), 119-123. 27 28 Spring 2014 PATIENT CARE SERVICES | RESPIRATORY With Every Beat and Breath, Respiratory Cares in the CSICU and MICU Christopher D. Kircher, MS, RRT-ACCS and Robin L. Smith, BS, RRT In the spring 2013 edition of News & Views, the trauma respiratory therapists were highlighted. For the general public and staff that work here at UMMC, the word Shock Trauma denotes the place where lives are saved! While many of our respiratory therapists frequently work in various trauma ICUs, there are more than a dozen additional critical care areas where work is performed utilizing the same skill set. The Medical Intensive Care Unit (MICU) and the Cardiac Surgery Intensive Care Unit (CSICU) will be the focus of this article for very good reasons. In March 2013, Robin Smith, BS, RRT, respiratory care supervisor, partnered with several UMMC physicians and a well-known member of the respiratory care field, Dean Hess, PhD, RRT, Assistant Director of Respiratory Care at Massachusetts General Hospital, to demonstrate that an appropriate respiratory care staffing model is essential in the ICU. “One of the defining characteristics of medical critical care is the demand for respiratory care services and the care of patients with respiratory failure” (Parker, 2013). In 2008, the UMMC MICU moved to the Weinberg Tower and expanded from 10 to 29 beds, with a much larger geographic footprint. Co-author of the same article, Carl Shanholtz, MD, medical director for the MICU and respiratory care department, has supported the development of the MICU for more than 15 years. In 2005, Shanholtz invited Hess to visit UMMC and evaluate the current state of respiratory care and provide recommendations as to what resources would be needed to bring the department to academic quality. Building from this assessment, the UMMC respiratory care department has grown to nearly 160 full-time therapists. For the MICU, this has resulted in regularly assigning three to four therapists per shift to the area; providing more attentive focus for these pulmonary compromised patients. Shanholtz commented that, “The partnership between the medical center’s leadership, the Department of Respiratory Care, the MICU staff, and the faculty to restructure the department resulted in improved utilization of respiratory services (Parker, 2013), a significant increase in ventilatorfree days, and contributed substantially to a reduction in mortality in the MICU patient population (Netzer, 2011). We have been redefined as one of the most pre-eminent academic respiratory care departments in the country.” As far back as 2001, when the concept of spontaneous breathing trials was first being proposed, the MICU struggled with an early adoption of this process, incorporating many of the ARDSnet-style ventilation models that were working to prove the benefits of lower tidal volume mechanical ventilation. Now in 2014, the MICU shares a collaborative approach to ventilator weaning with all other UMMC ICUs that includes better sedation management, breathing trials and earlier extubations. In addition to mechanical ventilation, the MICU therapists manage procedures that are not routinely performed in other ICUs. In a close relationship with the pulmonary critical care physician team, there are frequent bedside bronchoscopies that require increased teamwork with the assigned therapist to cover work responsibilities of the assisting therapist. It is the large number of these bronchoscopies that has prompted many of the MICU therapists to provide support for both the pulmonary function and bronchoscopy labs. The profile of the ventilated MICU patient is often one that involves some component of chronic obstructive pulmonary disease (COPD), and often a longer ventilatory course of treatment. Additionally, the liberation from ventilation can be more challenging as the COPD process leaves these patients with little pulmonary reserve. What is often a quick reduction in support for a postoperative surgical patient, the COPD patient requires close observation with each step in the weaning process. Similar to the neurotrauma intensive care unit’s support of patients with pulmonary compromise secondary to paralysis or other neuro injuries, the COPD patient is evaluated daily to assure that secretion management and respiratory medication delivery are optimized. At times, this results in a prolonged battle against mucus and pulmonary infections. The MICU therapist is there to provide airway clearance and to perform diagnostic procedures, including mini-bronchial alveolar lavage (BAL); all with the goal of minimizing the risk of ventilatorassociated pneumonia and prolonged ventilator length of stay. One floor below the MICU, an additional two to three therapists manage a much different workflow and patient population. The CSICU has a long history with respiratory therapy. Average ventilator length of stay continues to drop and is now closely monitored as a benchmarked data point of quality care. Each day may bring as many as five to six new patients requiring mechanical ventilation and other support. The respiratory therapist is in constant motion, moving between new admissions, SBT trials, routine therapy and extubations. As stated earlier, the goal in this surgical ICU is to wean and extubate patients as quickly as possible, and to facilitate continued on page 29. news &views Respiratory Cares in the CSICU and MICU, continued from page 28. discharge to lower levels of care. For many patients, this is the typical path. The challenge presented in this unit is the level of acuity as compared to many other CSICUs. The sicker heart and lung patients find their way to UMMC and require many of the same ventilatory strategies employed in both Trauma and the MICU. Additionally, the same secretion clearance and bronchodilator pathway used in neuro trauma critical care and the MICU is used in the CSICU. The partnership with pharmacy and medical leadership helped lead to the reduction in costs associated with an overordering of Combivent, an expensive combination of albuterol and Atrovent. These efforts, in conjunction with support of the Critical Care Operations Committee, keep the protocol moving to other ICUs throughout the facility. In 2012, a number of respiratory therapists were crosstrained to provide in-house support for an expanding adult and pediatric extra-corporeal membrane oxygenation program (ECMO). Functioning as “ECMO specialists,” these respiratory therapists work side by side with perfusionists and nurses that are also providing the same support in the CSICU, Trauma and Pediatric ICU. While “sitting pump,” the respiratory therapist does not function in the typical respiratory therapist role. However, their skill as a respiratory therapist provides a broad view of the patient condition, and therefore enhances the work of the ICU therapist providing care to the patient. During this year’s Valentine’s Day week snow storm, many of our staff stayed in local hotels to assure staffing for the next shifts. Several respiratory therapist trained “ECMO” specialists had a meaningful conversation one evening with the family of a patient receiving ECMO. The family commented that it is amazing to see the teamwork, dedication and coordination amongst care providers who are managing equipment that is far beyond normal comprehension. By simply saying thank you, this family provided an opportunity for staff to truly feel good about what they were doing and reaffirmed why they love working here at UMMC. Dan Herr, MD, medical director for the CSICU and chair of the Critical Care Operations Committee, commented that, “The team approach must be a clear focus at the bedside. Each specialty needs to understand the importance of roles, but at the same time be working collaboratively to ensure true evidence-based practice is demonstrated. Having interdisciplinary practice protocols alive at the bedside is key to ensuring important ICU goals like efficient time to extubation are reached. As sedation and ventilation are continuously managed, the aggressive use of noninvasive monitoring like end-tidal capnography must be available to ensure patient safety is maintained.” The delivery of nitric oxide is not only unique to the CSICU, but is widely used to treat pulmonary hypertension that can result from several issues associated with the cardiac patient. Whether to reduce afterload of a heart that has just undergone surgery, to help reduce pulmonary inflammation and increase oxygenation following a lung transplant procedure, or to treat primary pulmonary hypertension in the coronary care unit (CCU), the ability to induce pulmonary vasodilation is essential. While beneficial, the use of nitric oxide is very costly to deliver. Partnering with pharmacy, along with the leadership of Jonathan Gottlieb, MD, Chief Medical Officer, UMMC, and Herr, the CSICU has demonstrated that a conversion to Flolan®, another inhaled pulmonary vasodilator, could provide clinically equivalent outcomes at a significantly reduced cost. This focus on quality of care and fiscal responsibility will result in millions of dollars of savings and greatly reduce the mechanical hardware necessary to provide this clinical intervention. Similar to bronchoscopy procedures in the MICU, nitric oxide and Flolan® treatment often starts in the operating room and moves with the patient to the ICU. The use of nitric oxide and Flolan® requires the same level of teamwork to manage therapist’s time off the unit and away from their patients. According to Jeffrey Ford, MS, RRT, Director of Respiratory Care Services, “Usage and monitoring of nitric oxide is an essential component of the patients' care when receiving this therapy. Over time, we have been able to show a sustained decrease in our usage of the gas by moving to a less expensive alternative such as epoprostenol or Flolan®. Consequently, this saves the hospital hundreds of thousands of dollars annually, yet provides equivalent outcomes.” Upcoming issues will highlight the role and work of the respiratory therapist in the SICU, a large surgically focused intensive care unit. In addition, we will present the many challenges when caring for patients with elevated intra-cranial pressures in the Neuro ICU. And, finally, we will focus on the care of our smallest patients in the NICU and PICU that require a unique approach, but no less intense support. Parker, M., Liu, X., Harris, A, Shanholtz, C., Smith, R., Hess, D., Reynolds, M. & Netzer, G. (2013). Respiratory Therapy Organizational Changes Are Associated with Increased Respiratory Care Utilization. Respiratory Care, 58(3), 438-449. Netzer, G., Liu, X., Shanholtz, C., Harris, A., Verceles, A. & Iwashyna, T. (2011). Decreased mortality resulting from a multicomponent intervention in tertiary care medical intensive care unit. Crit Care Med, 39(2), 1-10. 29 30 Spring 2014 2014 Symposium “Advance Practice and a Look Forward” Christopher D. Kircher, MS, RRT-ACCS On Friday, April 11, 2014, the UMMC Respiratory Care Department hosted its second annual educational symposium entitled “Advanced Practice and a Look Forward.” Featuring lectures from respiratory therapists, physicians and nurses, the event drew an interdisciplinary crowd of over 150 attendees from Maryland and neighboring states. Additionally, we were able to feature thirteen product vendors that were a highlight during breaks and lunch. Knowing that UMMC has so many great stories and topics of interest to share, a committee set out in 2012 to re-establish a yearly educational opportunity for local respiratory therapists. Thanks to the quality of the lectures, the audience quickly expanded to nurses and physicians. All present were awarded 6.5 respiratory care continuing education credits or nursing professional advancement model credits. Participants attend one of the many lectures at the educational symposium. The 2013 event entitled “Respiratory Care on the Cutting Edge” was completely marketed through Facebook and other professional websites. Using social media prevented the expense of traditional mail and helped raise UMMC's awareness to a much broader audience. The Facebook page has continued to be a source of educational and general interest topics and is managed by Karoline Hoffman, RRT, a member of the respiratory care department. New for 2014 were several video advertisements put together by respiratory therapist Dan Whitt, RRT, who has a definite photographic talent. Dan has also helped promote our annual Ventilator 5K race, which is now in its 4th year. Jeffrey Ford, MS, RRT, Director of Respiratory Care, commented, “We were very interested in making this year’s event better than the last. Attendees provided feedback in 2013 and we responded with better handouts, free parking and an expanded vendor area. As many professions are requiring ethics continuing education points, we featured an excellent presentation by Marie Thompson-Smith, RN, educator and wife of respiratory therapy supervisor Rob Smith, RRT, entitled “Ethics of a New Healthcare Era.” This talk was very pertinent to the current changes in healthcare and provided a brief history on the development of healthcare ethics. With many UMMC hours of planning necessary for such an event to take place, the respiratory care department is proud to be leading by example and positively representing the profession in the continued on page 31. news &views 2014 Respiratory Symposium, continued from page 30. Left to right: Sabrina Cho, RRT; Archana Patel, RRT; Olga Fretts, RRT; Sayed Hashmi, RRT; Marissa Saunders, RRT; and Elina Greenan, RRT region. We are very thankful for the enthusiasm demonstrated by our speakers and their willingness to support this program. In 2014, Jay Menaker, MD; Michael McCurdy, MD; Megan Graybill-Anders, MD; Nader Habashi, MD; Carl Shanholtz, MD; Jason Custer, MD; Matthew Davis, RRT; Maria Madden, RRT-ACCS; and Greg Shelton, RRT, all presented lectures. Special thanks to symposium committee members Betty Leach; Marlin Martin, RRT; Francine Jones, RRT; Sabrina Cho, RRT; Maria Madden, RRT-ACCS; Karoline Hoffman, RRT; Hamid Reza, RRT; Daniel Whitt, RRT; Pete Saunders, RRT; Matt Davis, RRT; Paul Johnson, RRT; Rob Smith, RRT; Kate Dolly, RRT; Jeffrey Ford, MS, RRT; and Chris Kircher, RRT-ACCS. Additionally, a very special thank you to Samuel Gurmu and Green Valiant for their information technology support. Early planning for the 2015 event will begin over the next several months. We look forward to another exceptional educational offering and further opportunity to highlight the phenomenal team of respiratory care professionals and the care that they provide our patients at UMMC. Marie Thompson-Smith, RN Above, left to right: Devon Wilder, RRT; James Huff, RRT; Kathleen Slater, RRT; Nate England, RRT; and Diamond Watson, RRT Front row, left to right: Dennis Lee, RRT; Allison Giammanco, RRT; Lynda Sempele, RRT; and Brittany Rub, RRT Back row, left to right: Sayed Hashmi, RRT; Jean Peigne, RRT; Michiko Baker, RRT; Zoe Ireland, RRT; Jamie Morgan, RRT; Kathleen Slater, RRT; Paul Johnson, RRT; Francine Jones, RRT; and Hamid Reza, RRT 31 32 Spring 2014 PATIENT CARE SERVICES | CLINICAL NUTRITION A Team Approach to Tackling Big Nutrition Challenges in Tiny Infants Faith Hicks, MS, RDN, CSP, Senior Nutrition Specialist A multidisciplinary team recently developed a protocol aimed at optimizing the nutrition support of a very challenging group of critically ill infants – babies born with a single functioning cardiac ventricle. The more common of these defects is Hypoplastic Left Heart Syndrome. At birth, the single functioning ventricle pumps blood to both the lungs and the rest of the body. The single ventricle can only sustain this workload for a short period of time. Therefore, the babies undergo a series of three palliative surgeries. The risk of death between the first two can be high, but advancements in care, including nutrition care, are improving the survival rate. What makes this group of infants such a nutrition challenge? In the immediate post-operative period, children are very critically ill, on multiple vasoactive medications, have very high calorie demands, and are simultaneously fluid restricted. Additionally, the newborns are at high risk of Necrotizing Enterocolitis (NEC) due to poor oxygenation and gut perfusion. In the longer term, continued increased energy needs, gastrointestinal pathology, developmental delays, orofacial anomalies, vocal cord dysfunction, and impaired feeding skills may interfere with adequate nutrition. Some children require long-term tube feedings. During the phase between the first and second procedure, the mortality rate can be high. Optimal growth and nutrition are associated with lower mortality, better development and better surgical outcomes. The need for the nutrition protocol and other new protocols and procedures arose when cardiac surgeon Sunjay Kaushal, MD, came to the University of Maryland Medical Center (UMMC) two years ago. He brought with him the skill and experience to operate on these very fragile children. The feeding protocol team, led by pediatric cardiologist Carissa Baker-Smith, MD, MS, MP, and clinical nutritionist Faith Hicks, MS, RD, CSP, collaborated with nursing, the pediatric critical care nurse practitioner team, pediatric intensivists, and colleagues in Neonatology, Neonatal Nutrition, Pediatric Surgery, Pediatric Gastroenterology, and Speech-Language Pathology. Infants with single ventricle physiology undergo a series of surgical procedures. The team reviewed the literature for available evidence pertaining to the nutrition management of each phase, from preoperative care to postoperative care, and care after discharge. This was used as a basis for the nutrition protocol. Throughout every step of the way during the team’s series of repairs, they reviewed available evidence on providing nutrition to babies with a single ventricle. In other pediatric cardiac surgery centers, the use of standard practices, protocols, and very close monitoring has been shown to reduce the risk of NEC1,2, improve nutritional status, facilitate earlier attainment of calorie goals1, and shorten the length of stay2 of infants with single ventricle physiology. In developing UMMC’s protocol, the team reviewed available evidence to determine the safest way to provide early parenteral nutrition and advancement to enteral nutrition, while reducing the risk of and monitoring for NEC. The protocol includes supporting mothers in pumping breast milk for their infants, which has been shown in preterm infants to markedly reduce the risk of NEC3 and reduce the risk of other infections. Speech-Language pathologists play an instrumental role in transitioning from tube feedings to oral feeding, which affects length of hospital stay. Once patients are stable from a cardio respiratory perspective, Speech-Language Pathology is consulted to begin early oral-motor stimulation, if appropriate, and possibly oral feeding. The speech pathologist evaluates the patient based on his or her developmental level and makes recommendations which meet the patient at his or her current level of ability. Progression of oral feeding is related to the patient’s stability, endurance, and level of skill. The protocol continues on through the patient’s recovery phase and discharge to home. After discharge, close follow-up continues in the pediatric cardiology office, where growth and feeding are indicators of the infant’s overall health while he or she grows in preparation for the next stages of surgery. Future plans include monitoring and compliance to the protocol and associated outcomes. UMMC is a participating member of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) which supports interdisciplinary collaboration, evidence-based protocols, and recommendations for patient care. References 1. Del Castillo, SL., et al. Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Critical Care Medicine 2010; 11:373–377 2. Braudis N., et al. Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation. Pediatric Critical Care Medicine 2009; 10:460–466. 3. Sullivan S., et al. An exclusively human milk-based diet is sssociated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. Journal of Pediatrics 2010; 156:562-567. news &views Journal Club Condom versus Indwelling Catheter: A Randomized Trial Chiemerie E. Uche, BSN, RN, Medical IMC Chiemerie E. Uche, BSN, RN, hosted the March Journal Club meeting to review the article “Condom versus Indwelling Catheters: A Randomized Trial” (Saint, Kaufman, Rogers, Baker, Ossenkop, Lipsky, 2006) The purpose of this study was to compare the incidence of bacteriuria, symptomatic UTI, and patient satisfaction in hospitalized men requiring a urinary collection device, with either condom catheters or indwelling urethral catheters. Twenty percent of hospitalizedacquired bacteriuria is catheter related, and of these, the mortality rate is 10 percent (Feketa, Calderwood, Bloom, 2013). Research has shown that urinary catheters lead to more UTIs and are more painful and uncomfortable than condom catheters. Jamison et al. (2004) conducted a systematic review of randomized and quasi-randomized controlled trials and found conflicting and inconclusive results about the risks and benefits of the different types of catheters (Johnson, et al., 2001; Saint Lipsky, Baker, et al., 1999; Saint, Lipsky, Goold, 2002). Further, no studies were found that directly compared condom to indwelling urinary catheters. This study examined whether use of condom catheters would decrease the incidence of bacteriuria and symptomatic UTI compared to indwelling catheters. Researchers also hypothesized that use of condom catheters in cognitively impaired patients might be less beneficial than indwelling catheters for urinary monitoring. Using a randomized controlled trial design, condom catheters were compared to indwelling catheters for managing male patients with urinary problems not caused by obstructive uropathy or neurogenic bladder. Saint et al. (2006) screened 4,241 male patients 40 years of age and older at a veterans hospital in Seattle, Washington. Seventy-five participants were enrolled: 34 were randomized to the condom catheter group and 41 were randomized to the indwelling catheter group. The incidence of bacteriuria was the primary outcome measured. The development of symptomatic UTI, patient mortality, and patient satisfaction with the urinary collection device were also examined. To assess for bacteriuria, a urine sample was collected at the start of the study and then daily for the duration of the study. The maximum duration of followup for each participant was 30 days. Urine samples were withdrawn from the sample port with a sterile syringe for patients with an indwelling catheter. For patients wearing a condom catheter, the catheter was changed daily, and the first voided sample within an hour after catheter change was used. Patients’ mental status was assessed using the first eight items of the Mini-Mental State Exam (MMSE). Knowing whether or not a patient was cognitively impaired was important in evaluating the benefits of using condom catheters in patients with dementia. Patient satisfaction with a type of urine collection device was assessed using a previously developed standardized questionnaire (Saint, Linsky, Baker et al., 1999). The researchers used an intention to treat analysis and showed a lower incidence of bacteriuria and symptomatic UTI with use of condom catheters. Additionally, patients wearing a condom catheter were more likely to report their device was more comfortable and less painful. Finally, time of onset of bacteriuria was noted to be shorter in the indwelling catheter group compared to condom catheter group. There were several study limitations. First, a small number of participants (n=75) were enrolled in the study despite four years of intensive screening. Study eligibility requirements and patients’ refusal to be randomized to a catheter type limited enrollment. Patients were particularly resistant to being randomized to indwelling catheterization. The pool of potential participants included a large number of cognitively impaired individuals, with no surrogate decision maker, who were unable to provide informed consent, thus further limiting study enrollment Second, the study was conducted at a single site, which may limit generalizability. Third, only one specific type of condom catheter, available in various sizes and specifically designed to reliably stay in place, was used; this may limit generalizability to patient populations which use other types of condom catheters. Finally, randomization resulted in an unequal distribution of patients with dementia being allocated to the two groups (more were randomized to the condom catheter group). Findings suggest that a condom catheter may be a safer and more comfortable alternative than an indwelling catheter when there is no need to overcome obstructive uropathy or neurogenic bladder. Discussion: • The group thought the article was very relevant and timely considering CAUTI rates at UMMC. • Several staff members mentioned ongoing unit discussions regarding comparison of infection rates between indwelling urinary catheters and male external catheters. • Urinary infections are particularly challenging to manage in certain neurology patients. • The group agreed that it is very important that nurses actively advocate for discontinuing catheter use as early as clinically possible to avoid UTIs and other adverse events. • The group noted that staff must continue to be diligent in providing proper care for their patients requiring Foley catheters when condom catheters are not appropriate. • The upcoming trial use of the Reliafit male external catheter on several UMMC units was discussed as a possible solution to the problem of poorly-fitting condom catheters, which frequently leak and fall off. References Fekete, T., Calderwood, S., Bloom, A. (2014). Catheterassociated urinary tract infections in adults. UpToDate, http://www.uptodate.com/contents/ catheter-associated-urinary-tract-infection-in-adults. Jamison, J., Maguire, S., McCann, J. (2004). Catheter policies for management of long-term voiding problems in adults with neurogenic bladder disorders. Cochrane Database Systematic Review. doi: 10.1002/14651858.CD004375.pub2 Johnson, T., Ouslander, J., Uman, G., Schnelle, J. (2001). Urinary incontinence treatment preferences in longterm care. Journal of the American Geriatrics Society, 49(6), 710-718. Saint, S., Kaufman, S., Rogers, M., Baker, P., Ossenkop, K., Lipsky, B., (2006). Condom versus indwelling catheters: A randomized trial. Journal of American Geriatric Society, 54,1055-1061. Saint, S., Lipsky, B., Baker, P., McDonald, L., Ossenkop, K. (1999). Urinary Catheters: What type do men and their nurses prefer? Journal of American Geriatric Society, 47(2), 1453-1457. Saint, S., Lipsky, B., Goold, S. (2002). Indwelling catheters: A one-point restraint? Annals of Internal Medicine, 137(2), 125-127. 33 34 Spring 2014 UMMC Staff Presentations & Publications Peer-reviewed Publications and Presentations by Patient Care Services Staff. Notifications of Acceptance: July 2013 – May 2014 Congratulations to our accomplished staff! Publications Bolick, B., Bevacqua, J., Kline-Tilford, A., Reuter-Rice, K., Haut, C., McComiskey, C., Cavender, J., & Verger, J. (2013). Recommendations for matching nurse practitioner education and certification to pediatric acute care population needs. Journal of Pediatric Health Care, 27, (1), 71-77. Browne, N.T., Flanigan, L., McComiskey, C.A. & Pieper, P. (Eds.). (2013) 3rd Ed. Nursing Care of the Pediatric Surgery Patient. Sudbury, MA: Jones & Bartlett Publications. Connolly, M.E. & McComiskey, C.A. (2013). Common pediatric outpatient surgery. In Browne, N.T., Flanigan, L., McComiskey, C.A. & Pieper, P. (Eds.). 3nd Ed. Nursing Care of the General Pediatric Surgery Patient. Sudbury, MA: Jones& Bartlett Publications. Griffith, K., Couture, D., Zhu, S., Pandya, N., Johantgen, M., Cavaletti, J., Davenport, J., Tanguay, L., Choflet, A., Milliron, T., Glass, E., Gambill, N., Renn, C. & Dorsey, S. (2014). Evaluation of chemotherapy-induced peripheral neuropathy using current perception threshold and clinical evaluations. Journal of Supportive Care in Cancer, 22(5), 1161-9. Jones, K., Newhouse, R., Johnson, K., Seidl, K. (2014). Achieving quality health outcomes through the implementation of a spontaneous awakening and spontaneous breathing trial protocol. AACN Advanced Critical Care, 25(1), 33-42. McComiskey, C.A. (2014). Evaluation of the effectiveness of timed voiding for the treatment of pediatric dysfunctional voiding: patient characteristics and outcomes of care. Journal of Pediatric Surgical Nursing, 1,(1), 25-35. McComiskey, C., Tyler, R., & Rowen, L. (2013). Making the Case for a Nurse Practitioner Leadership Model: A Step-by-Step Conceptual Map for Nurse Practitioner Integration within Organizations: Identifying Key Components. In M. Bahouth, Q. Blum and S. Simone (Eds.) Nurse Practitioner Primer. Springer. Rose, D., Richter, L. & Kapustin, J. (in press). Patient experiences with electronic medical records: Lessons learned. Journal of the American Association of Nurse Practitioners. Schofield, D.L. (in press). Musculoskeletal Disorders in Women. In B. Hackley & J. Krieb (Eds.), Primary Care of Women: A Guide for Midwives & Women’s Health Providers. Boston , MA: Jones and Bartlett Publishers. Seidl, K.L., McComiskey, C.A., & Carey, S.S. (2013). When the torch passes, the light shines on (editorial). Bariatric Surgical Patient Care, 8 (2), 45-46. Presentations Banks, D., Yarbrough, K., & Ball, C. (2014, February). Stroke nurse fellowship: Improving quality in complex stroke patient care. Oral presentation at the AHA International Stroke Conference, San Diego, CA. Bassmann, G., Wells, C., Beans, J., Jenkins, T., & Verceles, A. (2013, May). Functional status upon admission to a longterm acute weaning unit and outcomes of ICU survivors receiving prolonged mechanical ventilation. Poster presentation at American Thoracic Society International Conference, Philadelphia, PA. Bautista, M., Blaber, B., Raine, E., & Harris-Williams, M. (2014, March). Best practices to prevent external ventricular drain-related ventriculitis. Poster presentation at the AANN 46th Annual Educational Meeting, Anaheim, CA. Blaber, B., Jaskulski, D., McCarthy, P., & Woltz, P. (2014, March). Implementing CCRT on a neurocritical care unit. Poster presentation at the 19th International Conference on Advances in Critical Care: CCRT 2014, San Diego, CA. Brumit, J., Connerney, I., Harris Wiliams, M., & Preas, M. (2014, March). Enhancing patient safety by improving hand hygiene practices through the integration of Maryland Hand Hygiene Collaborative participation and usage of The Joint Commission’s targeted solutions tool for hand hygiene and TeamSTEPPS tool. Poster presentation at the Maryland Patient Safety Center Conference, Baltimore, MD. Carco, D., Reece, M., Fouche, Y., Pollak, A., & Scalea, T. (2014, February). A novel financial incentive program successfully improved operating room efficiency. Poster presentation at the Pacific Coast Surgical Association 2014 Annual Meeting, Dana Point, CA. Couchman, C. (2013, October). Heartcode 201: Taking your heartcode to the next level. Oral presentation at Healthstream Inc., Nashville, TN. Custer, M. (2014, March). Reduction of central line associated bloodstream infections through the use of a designated unit-based infection control nurse. Poster presentation at the Maryland Patient Safety Center Conference, Baltimore, MD. Davis, M. (2013, July). Better precepting through a student identification system. Oral presentation at the Preceptor Workshop, Community College of Baltimore County, Essex, MD. Davis, M. (2013, August). The arterial blood gas and its effects on morbidity & mortality. Presented at Grand Rounds, Children’s National Medical Center, Washington DC. continued on page 35. news &views Presentations & Publications, continued from page 34. Davis, M. (2013, September). Revisiting arterial blood gases. Oral presentation at the Maryland/DC Society for Respiratory Care Annual Symposium: Conference by the Sea, Ocean City, MD. Page, J. (2013, October). Exercise for mental health: An inpatient activity. Poster presentation at the Annual Psychiatric Nurses Association, 27th Annual Conference, San Antonio, TX. Stewart, J. (2013, September). OT and child passenger safety: Car seats and beyond. Poster presentation at the Maryland Occupational Therapy Association Conference, Baltimore, MD. Davis, M. (2013, September). The use of high flow nasal cannula and passy-muir valve in liberating a spinal cord-injured patient from the ventilator: A case study. Poster presented at the Maryland/DC Society for Respiratory Care Annual Symposium: Conference by the Sea, Ocean City, MD. Ray, K., & Plummer, E. (2014, April). The use of post arrest hypothermia in trauma resuscitation patients: Is it useful? Poster presentation at the 17th Annual Society of Trauma Nursing Conference, New Orleans, LA. Stewart, J. (2014, April). Child passenger safety: Car seats and beyond. Poster presentation at the American Occupational Therapy Association Conference, Baltimore, MD. Dove, C., & Huffines, M. (2013, October). Transformational leadership: An interdisciplinary approach to morbidity and mortality meetings. Poster presented at the Seventeenth ANCC Annual Magnet Conference, Orlando, FL. Jones, K. (2014, May). Clinical Inquiry; Advocacy and Moral Agency; Response to Diversity; and Collaboration. Presented at the American Association of Critical Care Nurses National Teaching Institute, CCNS Pre-Conference, Denver, CO. Jones, K. (2014, May). Evidence-Based Practice: Improving Practice by Moving Sacred Cows out to Pasture. Presented at the American Association of Critical Care Nurses National Teaching Institute, Denver, CO. Madden, M. (2013, September). Successful apnea testing during VV-ECMO. Poster presented at the MD/DC Society of Respiratory Care Annual Symposium: Conference by the Sea, Ocean City, MD. Milone, J., Histand, A., Oyedeji, H., Hernandez, A., & Doyle, K. (2014, March). Breaking free from restraints. Poster presentation at the UHC 2014 NRP Annual Meeting, Amelia Island, FL. Mines, N., & Ruehle, K. (2014, February). Transplant center survey of CIBMTR internal assessment. Poster presentation at the Clinical Research Professionals’ Data Management Conference, Grapevine, TX. Noll, C., Brumbles, D., & Sadtler, K. (2014, February). Cultural changes to reduce use of seclusion and restraint: Creating a more positive work environment. Poster presentation at the American Nurses Association 8th Annual Conference, Phoenix, AZ. Roche, R. (2013, September). Developmental coordination disorder: What’s that? Oral presentation at the 33rd Annual Maryland Occupational Therapy Association Conference, Baltimore, MD. Rowen, L. (2014, March). The Ethics of Nurses and Chemical Dependency. Oral presentation at the 10th Annual Maryland Patient Safety Conference, Washington, D.C. Rowen, L. & Doyle, K. (2013, October). A Comparison of Leadership Development Interventions: Effects of Nurse and Patient Outcomes. Oral presentation at Special Topics in Trauma Care 2013, R Adams Cowley Shock Trauma Center, Baltimore, MD. Rowen, L., Doyle, K., Seidl, K., Woltz, P., Johnson, K. (2014, October). The Impact of Leadership Development on Patient and Nurse Outcomes. Accepted for oral presentation at the Eighteenth Annual ANCC National Magnet Conference, Dallas, TX. Seidl, K. & Johantgen, M. (2013, October). Using statistical process control for outcome measurement & evaluation. Oral presentation at the ANCC Annual Magnet Conference, Orlando, FL. Stanek, G. (2014, August). Changing a culture: A level I trauma center’s experience: The proof is in the outcomes. Accepted for poster presentation at the 6th International Conference on Patient and Family Centered Care, Vancouver, Canada. Stanek, G., Mulligan, K., Memphis, K., Motley, J., & Armostrong, L. (2014, April). Implementing patient family centered care improvements in level I trauma center. Poster presentation at the 17th Annual Society of Trauma Nursing Conference, New Orleans, LA. Szoch, S., Bigelow, B., & Kaiser, K. (2014, May). Evaluating the implementation of a neurologic assessment form for patients receiving high-dose cytarabine. Oral presentation at the Oncology Nursing Society 39th Annual Congress, Anaheim, CA. Togoika, J., Dale, R. & Riley, J. (2013, October). Nurses’ role in transitional care coordination and empirical outcomes. Poster presentation at the UHC Annual Conference, Atlanta, GA. Walburn, D. (2014, March). Improving the discharge process: An evidence-based approach focused on solid organ transplant patients. Poster presentation at the UHC 2014 Nurse Residency Program Annual Meeting, Amelia Island, FL. Wells, C., Jenkins, T., Beans, J., & Verceles, A. (2014, February) Association between quadriceps strength and sit to stand (STS) function in individuals receiving prolonged mechanical ventilation (PMV). Oral presentation at the American Physical Therapy Association Combined Sections Meeting, Las Vegas, NV. Congratulations and thank you to all UMMC PCS staff that have gone above and beyond to advance professional practice and science! If you are a PCS employee submitting scholarly work outside the UMMC organization, let us know if your submission was accepted and get recognized! Contact Nelia Zhuravel at email@example.com for more information. 35 36 Spring 2014 Achievements Congratulations to the following UMMC nurses promoted in February 2014! Professional Advancement Model Promotions Senior Clinical Nurse I Allison Enterline, BSN, RN Pain Service Amy E. Madren, BSN, BS, RN Neuro Trauma Intermediate Care April Sheppard, BSN, RN, CMSRN Medicine Telemetry Unit, 13 East/West Bridget Taylor, BSN, RN, CCRN Medical Intensive Care Unit Cherie Helfrich, BSN, RN Medical Intermediate Care Unit Danielle N. Evans, BSN, BA, RN, CCRN Medical Intensive Care Unit Donna Culbreth, BSN, RN Center for Diabetes and Endocrinology Kyle P. Jensen, BSN, RN, CEN Adult Emergency Services Gloria Aku Dzukey, BSN, RN Neuro Trauma Intermediate Care Molly Hutchins, BSN, RN, CCRN, FCCS Medical Intermediate Care Unit Jacqueline McLoughlin, BSN, RN Trauma Resuscitation Unit Samantha Christine Dayberry, BSN, RN, PCCN Multi Trauma Intermediate Care – 6 Jane Choi, BSN, RN, CNOR General Operating Room Senior Clinical Nurse II Jennifer Meyer, BSN, RN Neuro Trauma Critical Care Amy Caldwell, BSN, RN, CEN Trauma Resuscitation Unit Jessica Marie Farace, BSN, RN Multi Trauma Intermediate Care – 6 Courtney Cioka, BSN, RN Multi Trauma Intermediate Care – 5 Katherine A. McGinley, BSN, RN Multi Trauma Intermediate Care – 6 Kelly Ables, BSN, RN Multi Trauma Intermediate Care – 5 ... and in May 2014! Professional Advancement Model Promotions Senior Clinical Nurse I Amelia Wilson, BSN, RN Trauma Acute Care Andrea Muth, BSN, RN Cardiac Progressive Care Unit Angela Lewis, BSN, RN, PCCN Cardiac Progressive Care Unit Coty Smootz, MAT, MS, RN Shock Trauma Outpatient Pavilion Douglas LaTourette, MS, RN, CCRN Maryland ExpressCare Janis Marcella, BSN, RN Digestive Health Center Joshua Steen, BSN, RN Medical Intensive Care Unit Julie Schaller, BSN, RN, CNRN NeuroCare Intermediate Care Kimberly Godwin, BSN, RN Interventional Radiology Kristin Wilkes, BSN, RN, OCN Stoler Pavilion Megan Lilli, BSN, RN, CCRN Medical Intensive Care Unit Nisha Kumar, BSN, RN, FNE-A Orthopaedics Samantha Jacobs, MS, RN Pediatric Emergency Department Valerie Henshaw, BSN, RN, CCRN Critical Care Resuscitation Unit Senior Clinical Nurse II Julie Busseau, BSN, RN, CPAN Adult Post-Anesthesia Care Unit Kristen George, BSN, MPH, BS, RN, CCRN Critical Care Resuscitation Unit Louis Lee, BSN, RN, CCRN, CEN Critical Care Resuscitation Unit Mark Wieber, BSN, MA, RN, CNOR Shock Trauma Operating Room A special congratulations goes out to: Karen E. Doyle, MBA, MS, RN, NEA-BC, Vice President for Nursing and Operations at the R Adams Cowley Shock Trauma Center, has been appointed to the board of directors of Susan G. Komen Maryland, the state’s affiliate of the national foundation dedicated to finding a cure for breast cancer. Linda Goetz, MHS, CRNA, Director, Nurse Anesthetists, UMMC, has been elected as the Region 6 Director (Delaware, Pennsylvania, Ohio, Maryland and D.C.) of the American Association of Nurse Anesthetists (AANA). news &views Our Nurse.com GEM award winner! On June 10, 2014, Nancy Corbitt, BSN, RN, OCN, CRNI, was named the winner of the Nurse.com GEM (Giving Excellence Meaning) Award in the Clinical Nursing, Inpatient category for the District of Columbia, Maryland and Virginia region. Corbitt accepted the award and was recognized for her knowledge, expertise and skills as both a mentor and a patient advocate in front of a crowd of her peers and her daughter, a new nurse. Corbitt, a senior clinical nurse II within the Greenebaum Cancer Center, was one of three regional finalists from the University of Maryland Medical Center. Karen Yarbrough, MS, CRNP, was a finalist in the category of Advancing & Leading the Profession, as was Karen Hardingham, BSN, RN, CPST, for Home/ Community and Ambulatory Care. Left to right: Karen Hardingham, BSN, RN, CPST; Nancy Corbitt, BSN, RN, OCN, CRNI; and Karen Yarbrough, MS, CRNP Part of Nurse.comâ€™s Nursing Excellence Awards Program, the GEM Awards honor exceptional nurses in six categories regionally across the country. Nurses are nominated and selected by their colleagues, and regional winners, including Corbitt, will move on to compete in the National Nurse of the Year program. To learn more about the Nursing Excellence GEM Awards, visit www.Nurse.com/NursingExcellence. 37 38 Spring 2014 I Was Noticed The I Was Noticed program, a longstanding program sponsored by the C2X Employee Engagement Team, provides opportunities for patients, family members, and staff to recognize UMMC staff who are doing something great. I Was Noticed cards are located throughout the Medical Center and they can both be placed in an I Was Noticed box or faxed to 8-1880. Cards are entered in a monthly drawing and eligible employees win "free" vacation time! The Employee Engagement Team aims to recognize 36 employees annually. Listed are the winners from January through May of 2014. January Megan Garrity, RN Supplemental Staffing Manager: Tonja Marell-Bell “Thank you for the wonderful job you did Sunday night when you worked on Gudelsky 6E. I know you had a difficult assignment and then had the emergency with a patient at 6:30 in the morning. You handled it with the utmost professionalism. Thank you again!" from Joanne Kozlowski Ashleigh Barron, Physical Therapist Rehabilitation Manager: Krystal Lighty “Thanks for coming in on a weekend to assist with patient care. She was a good sport and very understanding when there was a scheduling mistake. We appreciate her flexibility and positive attitude.” from Kris Omanwa Joe Matthews, Patient Care Tech CSICU Manager: Mary Evans “Thanks for not only the excellent care provided to my father but also the positive attitude, friendly hugs and kind words to my mom and dad.” from Paige Sudbrook February April Lisa Mayo, Resident Pt. Discharge Asst. Greenebaum Cancer Center Manager: Nancy Gambill “Thanks for your loving care, always providing hope and going beyond what any patient expects. You are blessed. Love you from the bottom of my heart. You are special.” from Elizabeth Agron Santiago Cindy Darius, BSN, RN, Clinical Nurse II Neuro Care ICU Manager: Brigid Blaber “Thanks for all your help on Monday, April 14th (and Friday April 11th) :) I couldn’t have done it without your help & positive attitude.” from Rachel Rockefeller Meghan Kampmann, Vascular Technologist Surgical Vascular Bld Flw Manager: Sue Mcevoy “Thanks for maintaining the functioning of the lab alone during the snow storm for 3 hours while the rest of us were trying to come in.” from Sue and Peggy Catrina Mack, Secretary Anatomical Admin Services Manager: Stephanie Dampier “Thanks for coming to work during the winter storm and keeping the office going.” from Stephanie Dampier Darlene Wade, Patient Care Tech Radiology Manager: Mary Wall “Thanks for all the IVs on our outpatients, cleaning the CT tables. Michael & I could not have done it without you.” from Eileen Dentry Marieke East, Nursing Assistant Supplemental (STC Clinic) Manager: Tonja Marell-Bell “ Marieke is the most pleasant, hardworking and reliable worker. She is so efficient and gets so much done. I love working with you.” from Jean Holzman May Kevin Marshall, RN, Clinical Nurse II Cardiac Care Unit, Gudelsky 3W Manager: Lesli Bennett “Thanks for going above and beyond to review multiple portfolios with the April submission. Also, thanks for taking the time to help train Erin with portfolio review.” from Erin O’Grady and Greg Raymond March Nancy Zorn, Medical Lab Specialist II Pathology Administration Manager: Jonathan Cooper “Thanks for pulling all of the updated LabCorp certifications. I really appreciate your help.” from Ashley Hurst Ericson Bulatao, RN, Clinical Nurse II Main Operating Room Manager: Glenda Magpantay “Thanks for showing up during the storm.” from Margie Stickles Kate Piechocki, RN, Clinical Nurse II Neurotrauma IMC Manager: Lynn Armstrong “ Thanks for going above and beyond for a behaviorally complicated long-term patient. Her willingness to use personal resources and entertain the patient also assisted his progress during therapy treatment.” from Melissa Kellner Kristin Belangue, RN, Clinical Nurse II Med Endoscopy Manager: Marie Fortuno-Shifflett “Thanks for great teamwork. We had a extremely busy day. Sorry for the late lunch. You rock! Thank you for a wonderful day.” from Evette Everett Paul Chang, Medical Technologist II HLA Laboratory Manager: Michael Riley “Thanks for willingness to come in and assist deceased donors work-up although you were not on-call. Your assistance was greatly appreciated from start to finish.” from Madalyn Woodruff news &views Captain America: Law Breaker By Nicholas Edler, RN In the new Marvel movie, “Captain America: The Winter Soldier,” Captain America (played by Chris Evans) is seen coolly riding his new Harley-Davidson on the streets of Washington, D.C. While watching this, I can only think of one thing: Where is Captain America’s helmet? I am an intensive care unit nurse at the University of Maryland Medical Center, home to the nation’s first and only integrated trauma hospital. We regularly see motorcyclists survive devastating crashes if, for no other reason, than because they were wearing a helmet. For years, Marvel Entertainment, a Walt Disney Company, has had superheroes riding motorcycles without helmets — including Wolverine, Ghost Rider and the Punisher. This trend is also exemplified by DC Comics’ portrayals of Batman and Cat Woman riding the streets of Gotham City without a helmet. While this flippant disregard for safety regulations bothers me on any given day, I tend to keep it to myself since these characters are branded as dark, “bad-boy” personalities. But not today. This is the Captain America we are talking about, the “boy scout” of all superheroes. This law-abiding soldier who is meant to exemplify the ideal role model citizen is seen in the movie deliberately breaking D.C.’s helmet law. Since the first film premiered, this PG-13 movie is spun to be a family-friendly film, as evidenced by the countless associated toys and products released and targeted to younger children. These children are often highly impressionable — especially when it comes to the choices of superhero-like characters. What is mom to say when her little boy doesn’t want to wear a helmet because Captain America doesn’t wear one? I’m not saying that children are only influenced by what they see, but Captain America isn’t helping to quash the supposition that helmets are geeky. If any fictional superhero could make wearing a helmet cool, it would be Captain America. Heck, normally it’s the faceless henchman who wears a black-tinted helmet during the motorcycle chase, as seen in James Bond’s “For Your Eyes Only.” Is this the type of individual we want to associate with helmets? Captain America, or should I say, Steve Rogers, is far from invincible. Yes, he has extra strength and agility, but he also gets hurt just like the rest of us. If he were to fall off his motorcycle on I-495 without a helmet, there would be no walking away unharmed. It’s not a nice thing to think about, but it’s reality. Captain America paints the picture of “cool, “ riding his Harley with a leather jacket and jeans, slicked back hair, and ... no helmet. This is not the image we want our kids to recall when they hop on their bicycles. This one little scene showing negligence of motorcycle safety is part of a bigger trend in Hollywood, where characters frequently disregard safety procedures. Movie producers and directors need to be more responsible with the representation of the “good guys.” After all, these are the characters that many young kids dream of being one day, and we adults use these as a form of incentive for eating vegetables, drinking milk and even going to bed on time so the little ones can grow up big and strong like, well, Captain America. Throwing a helmet on the guy would take so little effort, but go a very long way. Nicholas Edler is a clinical nurse I in the Medical Intensive Care Unit at the University of Maryland Medical Center. This article is written in a personal capacity and is independent of his affiliation with the medical center. His email is firstname.lastname@example.org. 39 22 South Greene Street Baltimore, Maryland 21201 www.umm.edu Clinical Practice Update