Nursing Biennial Report 2013-2014
Welcome
As a Magnet 速 organization the opportunity to recognize our professional practice is an honor as it demonstrates our continued journey and commitment to service excellence. I am pleased to share the 2013-2014 Nursing Annual Report for University Hospital, which showcases the great work and contributions made by nurses throughout our hospital. This report features select accomplishments that reflect the on-going commitment to adapt to Magnet changes as well as innovation brought about with health care reform. Our shared governance structure transitioned to a new professional practice model and re-designed the various councils to better serve the needs of nurses and support more engagement of front line nurses. As you read through this report, you will discover evidence of how University nurses have embraced a deeper focus on patient and family centered care as well as utilizing innovation in practice and technology to foster the safe delivery of care both. The infusion of evidence-base research has become the basis to guide nursing practice at University Hospital so that the environment patient care is delivered support quality outcomes. It is an honor that University Hospital is consistently recognized as having the Best Nurses in the CSRA by the National Research Corporation. Indeed our nursing staff takes their profession, passion and commitment to care for others seriously which is evident as they embody nursing excellence in all that they do. It is an honor and privilege to serve such an amazing team!
Sincerely,
Lynda Watts, RN, MSM, BSN, NEA-BC Vice President of Patient Care Services and Chief Nursing Officer
Excellence IN PRACTICE In 2013, the UH nursing staff completed the
C – Caring and Healing Environment: We are
transition to a new professional practice model.
committed to creating an environment to foster
The previous practice model was complex,
patient-centered care based on the unique
informed by an eclectic set of theoretical system
physical, psychological, spiritual, and emotional
theories and models with nursing application.
needs of each patient.
After careful deliberation, the nursing SG representatives created the new model consistent with our philosophy and values, as well as our previous systems approach. Depicted in
T – Technological Advancements: We are committed to using innovative technology to support and promote highest quality of care.
the figure below, the Excellence in PRACTICE
I – Interdisciplinary Collaboration:
model is framed by University’s commitments
Interdisciplinary collaboration is critical to
of Quality, Service, Teamwork, Community,
ensuring comprehensive care within our system
Affordability, and Professionalism and the values
and involves respecting the skills and knowledge
of ongoing professional development; high-
of each team members to optimize outcomes.
quality, patient-centered care; and collaborative teamwork. Excellence is an umbrella concept that encompasses high-quality care, safety, and the interdisciplinary nature of nursing with each of the following constructs identified: P – Patient-Centered: The patient/family/ community needs guide the focus of our care. We respect the individuality of our patients and advocate for quality care sensitive to their needs. R – Respectful Relationships: The contributions of all members of the healthcare team are to be recognized and respected and it is nursing’s ethical responsibility to treat others with respect and promote environments conducive to high quality healthcare. A – Accountability and Autonomy: Nurses have the authority and responsibility to practice in accordance with established patient care standards. This accountability is to self, patients, members of the healthcare team, organization, and external agencies. Nurses at University have the autonomy to influence patient care standards at the unit and division level and to make choices regarding how to provide care to meet the individual needs of patients within the care delivery system.
C – Continued Professional Development: We are committed to promoting ongoing professional development to support evidencebased care and nursing engagement. E – Evidence-Based Decisions: Evidence-based practice is foundational to the care provided and nurses are expected to incorporate the bestavailable information into the creation of practice standards and daily patient care.
Patient & Family Centered:
Jernigan Cancer Center Family Waiting Room Patient-Family Centered Care is fundamental to our PRACTICE professional practice model. Our nurses do not consider family members as “visitors” but as integral to our patients. We want families to find University a place to help impart ease and comfort while their loved ones receive care. The Jernigan Cancer Center Family Waiting Room renovation is a shining example of our emphasis on patient-family centered care. Looking at the Jernigan Cancer Center Family waiting room now, it’s difficult to imagine the former area where families were confined to waiting, praying, resting and communicating with extended family and friends in a small outdated space with no windows and only one Caring Bridge computer station. Thanks to the support of the Volunteer Board of University Hospital and proceeds from the Jernigan Memorial Golf Tournament, families are now able to gather, support one another, and retreat in an inviting and comfortable space. The room is beautiful, with bright natural lighting, and includes a kitchenette, play area for children, private bathroom, and two computer stations with access to Caring Bridge. It helps to make the uphill battle that the entire family fights when a love one is diagnosed with cancer more bearable
Jernigan Golf Tournament to be allocated for
and is reflective of the Foundation’s mission to care
this renovation, the Jernigan Golf Tournament
for our community and families facing a battle.
Sponsors, the Volunteer Board, the Hospital Board, the Foundation Board, the Projects Department,
A special thank you to the Jernigan Family
and to the families and staff of the Jernigan
for allowing proceeds from the 27th Annual
Cancer Center for their input.
MOTHER’S CHOICE — for patient/family focus University’s W.G. Watson M.D. Women’s
Breastfeeding has come “full circle” and is
Center has offered Mother’s Choice
now even an international quality imperative,
“service” for well over two decades—doing
a Healthy People 2020 goal, and one that
whatever we could to honor our patients
The Joint Commission has also introduced
and families “special” requests. As our
as a Core Measure. We are in the initial
namesake, Dr. Watson, said … “Service and
stages nationally of public reporting on
Kind Words.” Every one of us deserves
lactation! Moms make choices on things
to celebrate/experience events in our life
like this, things they believe are (or are not)
in our very own way. And a birth is one
important to them and it’s our role in nursing
of the most memorable times in our lives!
to educate and support them as much as
The Golden Hour is one example of this
we safely can! If parents have requests that
patient and family focus.
are outside the “norm,” we look into options, check the literature, find out what others
The Golden Hour is that first hour after
do, and strive to provide the best of care.
birth which has been proven to be
We look to see how we can help!
critical for bonding and establishing successful breastfeeding. In 2013,
Evidence-based care is a cornerstone of
our Women’s Center nurses fully and
our nursing practice. And we definitely
formally implemented The Gold Hour
want and need to stay the front-runners,
to promote skin-to-skin contact with
delivering the highest standard of care — the
minimal interruption as our standard of
very best practice! Nurses have the distinct
care. Historically, babies were whisked
honor of helping people; we are patient and
away from mother moments after birth
family advocates by profession! Being a
to be measured, weighed, inspected, and
Magnet hospital means you have the very
warmed. However, as long as the mother
best of the best of nurses; and those nurses
and baby are healthy there is no reason
are focused on delivering the highest quality
to move the baby to the nursery and
of care and compassion. What better time
disrupt this first hour. We find most of our
to start than the Golden Hour?
patients will immediately want to bond with their new baby and most will want to breastfeed; that’s the standard and we know it’s the best. We are still sensitive to those mothers who may not want or be able to do so, hence MOTHER’S CHOICE.
Respectful Relationships
Streamlining the Emergency Room Experience
AIDET Respectful Relationships The Emergency Department (ED) is the first contact many of our patients Respectful relationships are a fundamental
have with University Hospital and our
component of our PRACTICE model. Our
ED nursing staff strives to optimize
nurses strive to embed the highest standards of
patient experiences. In 2013, the UH
customer service in our patient-centered care. In
ED nurses implemented a unit-based
2013, University embraced the use of the AIDET
charter to design and implement
communication model to enhance respectful and
processes to improve the triage
courteous communications between all individuals
process for patients.
within the facility. The new process ensures that a What is AIDET? AIDET is a mnemonic reminding us
specially trained triage nurse greets
of the components of respectful communication.
and assesses patients upon arrival to
It all starts with Acknowledging another person’s
registration, determining the acuity
presence with a smile or a word, then Introducing
using a 5-point scale. This early
ourselves and our purpose in a respectful way. We
assessment and triage allows patients
share the Duration of what we will be discussing or
to be more quickly directed to the
doing, so that they understand how long it will take,
appropriate area of the ED, facilitating
then Explain what we need to do and what will be
timely and effective care.
involved. Finally, as the interaction ends, we Thank the person to let them know we are appreciative
The ED nurse educator, Denise Simon,
that they placed themselves in our care. We also
BSN, CEN became a Triage First
take this opportunity to invite any further questions
trainer so that she could educate ED
or needs.
nursing staff on implementation of this evidence-based set of resources.
We have diligently worked to “hardwire” the
In the future, classes will be offered
AIDET process into our nursing staff, as well as
monthly, as the goal is for all nursing
all others at University. In early 2013, 100 percent
staff to complete the training.
of staff completed training in this communication method. We are seeing related improvements in
In 2014, to further benefit our ED
communications, levels of patient involvement,
patients, we added ER Express,
clinical outcomes, and patient satisfaction. Using
an online program allowing pa
AIDET has guided consistent and empathetic
tients to identify when the next ED
communication with patients and families, helping
“appointment” is available, as well as
us to always demonstrate our concern and
appointment options in our the UH
appreciation.
Prompt Care settings.
NEW UNIFORM POLICY
As part of promoting respectful
This move to color-coded professional
relationships, our nursing staff recognizes
attire was adopted as an evidence-
the importance of professional appearance
based project by nursing with follow-up
to instill confidence by patients and our
patient surveys planned. We feel that it
colleagues. In 2013, University’s leadership
is important for our patients to be able
considered the transition to color-coded
to recognize their nurses and to dress
professional attire for staff in several
in a way that presents a professional
disciplines, including nursing. Nationally,
appearance consistent with our licensure.
other facilities have adopted color-coded uniforms to enhance patients’ ability to differentiate between the roles of staff as a means of enhancing safety and customer service. As the literature on this subject was largely anecdotal, our nurses conducted a brief patient survey to identify our patients’ needs prior to transitioning to the new color-coded dress policy. In August 2013, after obtaining IRB approval, the nurse researcher surveyed patients on eight units. Patients verbalized some difficulty in knowing staff roles and overwhelmingly indicated that color-coded uniforms should help in this regards. They were complimentary of existing efforts to identify staff, such as name tags, consistent self-introductions, and “white boards” but also described reliance on their ability to read staff members’ name-tags and recall the introductions. Thus, the move to colorcoded professional attire was made in September to enhance patient safety and satisfaction. University staff nurses now wear royal blue uniforms throughout the organization and other staff members dress according to their discipline’s dress code.
Accountability & Autonomy
Shared Governance
University’s nursing Shared Governance (SG)
The division-level SG now consists of three
program is designed to provide a structure for
councils and a number of committees and
nursing staff involvement, accountability, and
workgroups. The councils are Transformational
promotion of quality care, ultimately improving
Leadership Council (TLC), Exemplary Professional
patient outcomes. In 2012, the nursing staff
Practice Council (EPPC), and Structural
decided it was time to revise the existing SG
Empowerment Council (SEC).
structure, in place almost ten years. The new streamlined model was implemented in late
EPPC: The EPPC oversees evidence-based nursing
2012 and early 2013; it includes a more simplified
practice, practice innovation, and research and
division-level council structure and a more
includes standing committees such as the Practice
consistent unite-level structure.
Committee.
Our SG structure moves decision-making closer to
SEC: The SEC oversees professional engagement,
the point-of-care, with Unit Leadership Councils
professional development, teaching and role
(ULC) known as “triads.� Triads are comprised
development, community involvement, and
of two unit nurse representatives (one from
nursing recognition, with relevant committees
each shift) and the nurse manager; triads work
appointed.
closely with unit staff to identify and address opportunities for improvements related to patient
TLC: The TLC is responsible for the overall nursing
care and unit processes. Unit-level SG projects are
strategic plan and consistency of nursing care
accomplished through unit-level committees and
throughout the organization.
work groups. Triad members also represent their units on the division-level SG councils.
Shared Governance Touchback Sessions
Unit Based Triad Accomplishments
Each month, unit representatives to the EPPC and SEC present their unit’s charters, describing unit-based initiatives, goals, progress, and outcomes. Examples of recent unit specific accomplishments include:
Cardiac Cath Lab
10W
Improvements resulting in decreased
Enhanced patient education
radiation exposure for staff
processes, ensuring resources readily available for staff on needed topics
Cardiovascular PACU Evaluation and selection of new cardiac
GYN
pillow, associated with increased comfort
Testing use of new patient transfer
and zero dehiscence rate
equipment to increase patient com fort moving from stretcher to bed while
6NS and CV3
promoting safe patient handling
Pilot of “pass with care” initiative resulting in decreased patient falls
OB Pyxis reorganization enhancing availability
7NS
of needed products while increasing
Implementation of pharm tech role
savings
to enhance patient education while supporting nurses with decreased
SCN
medication administration time
Increasing awareness of and participation in continuing education opportunities
8NS Enhanced hourly rounding with
ED
emphasis on identification of patients at
Instituted Triage First improving the
heightened risk for falls and to ensure that
registration and triage process for ED
appropriate safety measures in place
patients
10NS
Surgical Services
Established quarterly unit newsletter to
Creating one combined resources for
promote communication and collegiality
policies, procedures, and infection control
among staff
guidance for use by all surgical areas
Power Hours
7NS Pilot: Addition of Pharmacy Technician Role
In December 2013, the 7NS nursing staff participated in a project designed to measure and review the proportion of their time spent in various direct and indirect patient care, activities, with an aim to consider staffing options to increase their availability to focus on professional nursing tasks. They Lynda Watts, RN, MSM, BSN, NEA-BC Vice President of Patient Care Services and Chief Nursing Officer
found that they spent more time in medication administration activities than reported by other facilities. In 2014, the interdisciplinary team reviewed options and elected to conduct a pilot adding a pharmacy technician role on the nursing unit to support their medication
Lynda Watts, our CNO, is a great proponent
administration activities. A pharmacy
of nursing autonomy and recognizes that our
technician would be able assist the
nurses are the best resources when it comes to
nursing staff with pulling medications
identifying nursing needs. In mid-2014, Lynda
for the Pyxis, obtaining the medication
hosted a series of “Power Hours”—brainstorming sessions with groups of nurses representing diverse units invited to explore what our strengths and opportunities for improvement. During the sessions, issues such as nursing retention and recruitment, staffing and support roles, nursing satisfaction, patient flow and placement, and equipment availability were discussed. A number of initiatives emerged from these conversations. For instance, in summer 2014, a number of plans were implemented to enhance nursing retention. At the same time, nursing and human resources launched the “80 in 80” plan aimed to hire 80 new nurses within 80 days. The goal was exceeded, resulting in many new nurses joining our staff. To optimize recruitment, we instituted Magnet Mondays. Every Monday from 9 a.m. until 11 a.m., a recruiter is available in the hospital lobby to speak with nurses interested in careers at University.
history, contact patients’ pharmacies or providers to obtain accurate medication reconciliations, etc. This project was successful. Based on the evidence from 7NS, the project is being replicated on 8NS in late 2014.
Nursing Strategic Plan
In 2013, the Shared Governance representatives reviewed, updated, and approved an ongoing strategic plan. The Professional nursing staff within University Hospital has a robust strategic and operating plan consistent with that of the
The following depicts the primary goals under the categories of People, Growth, Affordability, and Quality.
organizational plan. The first component is the strategic plan, which includes the cornerstone
PEOPLE
elements of the mission; vision, commitments and
Nursing at University will attract,
long term strategic goals framed around five pillars: SERVICE, QUALITY, AFFORDABILITY, PEOPLE, AND GROWTH. The second component is the annual operating plan, which consists of the organizational priorities, the teams accountable for translating the priorities and tactics into action, and the performance measurement criteria. Both components of the plan are influenced each year by the data generated from numerous sources including, but not limited to, staff’s perceptions of the professional practice environment survey, patient satisfaction surveys, and the work of the Shared Governance Councils.
Long-term Focus: The Strategic and Annual Operating Plan is the basis upon which the Vice President of Patient Care Services and the Division is evaluated. Within the strategic framework are the University Health Care Hospital mission, vision and commitment; definition of Nursing, goals, philosophy and objectives.
retain, and develop excellence in professional nursing dedicated to evidence based practice and high quality patient-family centered care. GROWTH Nursing at University Hospital will engage staff in activities that promote expanding services for our community. AFFORDABILITY Nursing at University Hospital will be engaged and supported by a professional practice culture and climate which supports cost effective care delivery. Through structural empowerment nursing will design and contribute to the development of the future cost containment strategies. QUALITY Nurses at University Hospital will place quality-caring relationships at the center of our practice resulting in safe compassionate care demonstrated by excellence in patient outcomes.
Caring & Healing Environment
Sacral Preventative Dressing For Caring and Healing Environment
As an organization consistently seeking ways to promote a caring and healing environment, University Hospital has a long
Safe Patient Handling Program
history of extremely low pressure ulcer prevalence. However, the nursing staff
In March of 2013, University Hospital implemented a safe patient handling program to prevent injuries and ensure safety for patients and staff. The
continually seeks opportunities to further decrease, if not eliminate, ulcer formation all together.
development of our safe patient handling program
In mid 2013, after performing months
began in October 2011 with an equipment
of testing showing consistent positive
expo to display transfer and mobility devices
outcomes, the nursing staff decided to
by ArjoHuntleigh, Inc. Staff were encouraged
implement the use of a new foam sacral
to “test drive� the equipment and submit
preventative dressing. They then continued
recommendations for purchase. Equipment was
to be engaged with the implementation
purchased based on these recommendations in
of this new dressing by aiding in the
2012. For a period over 6 months, employees
development of policies, in services, and
were trained on the safe mechanics of lifting
modifications to the electronic health
and use of the transfer and mobility equipment.
record as well as the development of a
To ensure mastery of necessary skills, each
nurse driven protocol to address at risk
employee was required to return-demonstrate
patient populations.
the use of any equipment/devices purchased for his/her unit. Practice standards and
Once substantial education was completed,
computerized documentation have been revised
the use of the new sacral dressing was
to accommodate the changes in clinical practice. While hospitals have traditionally relied heavily on body mechanics training, there is considerable evidence-based research that indicates this training alone is not effective in preventing strain/
implemented house-wide for those patients who met high-risk criteria. The use of this dressing has now aided in a measurable decrease in the development of new sacral pressure ulcers, as evidenced by our 20132014 Quarterly Preventative Studies.
sprain injuries associated with patient lifting. The United States Bureau of Statistics, based
Number of Sacral Ulcers Q4 2012--Q4 2014
on information from the Department of Labor Occupational Safety and Health Administration
5.5
(OSHA) indicates nurses and patient care
4.5
assistants are consistently within the top ten of all
3.5
occupations at risk for physical injuries. Two years prior to implementation of the program, greater than 15% of all employee injuries were the result of patient care related strains/sprains. The incidence of patient-care related strain/sprain injuries was cut in half following introduction of the equipment.
4
3
3
2.5 1.5 0.5 0 -0.5 Sacral Ulcers
Q4 2012 3
Q1 2013 4
Q2 2013 3
Q3 2013 0
0 Q4 2013* 0
0 Q1 2014 0
0 Q2 2014 0
0 Q3 2014 0
0 Q4 2014 0
Technological Advancements
EPIC: Technology The EPIC electronic health record (EHR) is a key component in improving patient safety, clinical quality
UH has consistently evaluated emerging technology for evidence that it would favorably contribute to the outcomes of our care. In 2013, in addition to the continued implementation of EPIC, our electronic health record (EHR), a number of other resources were tested and several implemented.
otherwise be performing chest compressions. Most importantly, it leads to improved patient outcomes, our final goal.
outcomes, service, and operational performance. University nurses have historically been instrumental in the design and implementation of our electronic resources and EPIC was no exception. University implemented the EPIC EHR in December 2012 and early 2013. Throughout the planning phases and ongoing evaluations, clinical nursing staff members have been included in the decision-making processes related to enhancing our documentation system to not only meet regulatory guidelines, but to improve efficiency in providing patient care. Engaging nurses in throughout the process empowers them to improve professional nursing practice. An example is the development of Best Practice Advisories (BPAs) which alert the nurse to required documentation components, such as home medication review, immunization screening, and heart failure education. Optimization of the EHR is an ongoing process that will assist in keeping ahead of inevitable changes in health care, while maintaining excellence in nursing.
LUCAS 2 technology In 2013, the emergency was very fortunate to obtain the LUCAS 2 compression system, an example of new technology enhancing clinical outcomes. The LUCAS 2 system is designed to deliver uninterrupted compressions at a consistent rate and depth, in order to facilitate return of spontaneous circulation. As any nurse knows, performing manual CPR is difficult and tiring. However, high quality CPR is vital in order to deliver oxygen to organs while maintaining sufficient coronary perfusion. LUCAS is portable, lightweight, and easy to use. It frees up a nurse or other staff member who would
AccuVeins have arrived ... for technology The AccuVein 400 is a vein illuminator that helps nurses and other clinicians locate superficial veins up to 10mm. It operates using infrared light to detect veins beneath the skin, then projecting the position of the veins on the skin surface directly above the veins. During July and August, 2013, a clinical evaluation of the device was conducted by clinical nurses. Based on overwhelmingly positive reactions from both staff and patients, 21 devices were purchased. All relevant nurses were educated on the use and maintenance of the device, including vein location techniques, in October 2013, when the devices were made available throughout the organization.
Interdisciplinary Collaboration
Nursing is represented as essential part of the many UH interdisciplinary teams. Our teams have successfully pursued and maintained quality resulting in a number of national certifications and/or recognitions, including heart failure, chest pain, stroke, total joints, breast health.
and physicians to assess the patient’s functional capacity. The change in functional capacity over time is visible to all care providers. n
Partner with the patient, to understand what goals they want to achieve considering their current condition. Focusing on the goals of the patient help us to identify their barriers and facilitate a partnership to make a difference in the transition of care to home or community. The goals and interventions are added to the care plan and discharge instructions which help the patient achieve their goals.
n
Dr. A. Bleakley Chandler states “I have enjoyed our heart failure rounds over the last six months [starting in Oct. 2013]. I think it has improved the care of our patients. First, the nurses caring for these patients have gotten really good at understanding them from a heart failure point of view. They have learned the difference between systolic and diastolic heart failure and the appropriate medications. They have learned the importance of tracking their [the patient’s] weight as well as their functional class and short term and long term goals. We have also focused on advance directives. In addition, our team including Terri DeFusco and Jeff Langford, PhrmD., frequently pick up on patients who are not on appropriate medications, need to have a discussion about an AICD or who need a Cardiology consult. All in all our heart failure patients have directly benefited from our rounds.”
Heart Failure Interdisciplinary Team: The Heart Failure Interdisciplinary Team (HFIT) is nurse led collaboration whose goal is to provide the highest quality care to the patient. An interdisciplinary team offers their professional knowledge and experience to solve problems to improve patient outcomes. The HFIT consists of Physicians, Heart Failure Program Coordinator, Nurse Managers, Staff Nurses, TeleHealth Nurses, Pharmacists, Registered Dieticians, Case Management, and Performance Improvement. Fall 2013 University Hospital’s Advanced Heart Failure program was surveyed by The Joint Commission, who identified opportunities for the organization to improve care of the heart failure patient across the continuum. As Heart Failure Program Coordinator and Leader of the HFIT, Terri DeFusco, BSN, RN has spearheaded the following initiatives to achieve success with TJC identified opportunities for improvement: n
n
An easy self-assessment tool that would help any care giver to understand the patient’s perception of heart failure wellness. The stoplight tool provides a visual for signs of worsening HF and reminds patients to call their doctor for assistance rather than going to the emergency room. The stoplight tool is written at a fourth grade level to reach our demographic. Laminated copies of the stoplight tool are hanging in the patients rooms throughout the hospital as a visual reminder for the staff, patient and family. The New York Heart Association (NYHA) classification of functional capacity was chosen as the method to monitor patient’s progress throughout the continuum of care by our team. This scale was added to our EPIC admission navigator and care plan for the nursing staff
Through the direction of a nurse led interdisciplinary team by Terri DeFusco, BSN, RN the opportunities identified by TJC to strengthen the effectiveness of University Hospital’s Advanced Heart Failure Program have been implemented. Using feedback from frontline nursing staff and the intellectual capital of the team, the initiatives have made a tremendous difference in the ability of all disciplines to assess and clearly understand the patient’s perception of self and personal goals that result in improved
TAVR PROGRAM:
The TAVR (transcatheter aortic valve replacement)
Risk was approved by the FDA and CMS which
program is another example of a highly visible,
increased the new referral numbers to 10 plus
nurse-coordinated program. The TAVR program
patients per Tuesday.
was envisioned by Drs. Les Walters/Kraig Wangsnes
and Timothy Hunter during a conference in June
By December 2012, the need for additional clinic days
2011. This new technology that was previously only
and more clinic space was evident. The Structural
available in Europe was soon to be available to
Heart Clinic was formed and began seeing patients
commercial sites in the United States pending the
in a shared area with the Weight Management Clinic
outcome of the Partner Trial.
located on the first floor of the Heart and Vascular
Institute in January 2013. (Clinic days are now every
They discussed having a TAVR program at University
other Tuesday throughout the month.)
Hospital with the Administration. The Administration/
Board approved the possibility of having a TAVR
On February 5, 2013 the first TAVR procedure was
program. University Hospital first had to apply
successfully performed in the hybrid OR.
to be considered a possible TAVR site and had to
meet very strict requirements set forth by the Food
By the end of December 2013 we had screened close
and Drug Administration (FDA) and the Center
to 100 patients identified with Severe Aortic Stenosis;
for Medicare Services (CMS) as well as with the
completed 25 successful TAVR cases; referred 12
Edwards Lifesciences Company (the only TAVR
patients for traditional SAVR and continued to follow
valve company at that time). Once the requirements
patients who are in need of TAVR but have not quite
for both the facility and the physicians were provided,
met the criteria.
University received approval to start their program.
(Summer/June 2012).
To date, our hospital has completed a total of 31
TAVR cases. We have a 100% procedural success
They had to hire a coordinator for the program and
rate (which means that 100% of our patients have a
establish a formal clinic to screen potential patients
successful implantation of their new valve and leave
diagnosed with severe aortic stenosis as defined by
the OR alive) A statistic that is shared by only a few
the American Cardiology College organization (ACC)
hospitals in our Region.
Severe Aortic Stenosis is defined as: A Jet velocity
> 4.0; Mean Gradient > 40 mmHg; Valve Area < 1.0
The TAVR program (Structural Heart Clinic) continues
cm2/m2 or a valve index < 0.6. In addition, to be
to grow and flourish under the Collaborative Heart
eligible for the TAVR procedure, the patients had to
Team made up of one RN and 8 Physicians (2
be seen by 2 cardiothoracic surgeons and deemed
Interventional Cardiologists; 2 CT Surgeons;1 invasive
inoperable (not candidates for traditional open
cardiologist; 1 cardiac anesthesiologist; 1 Radiologist)
surgical aortic valve replacement or SAVR).
and many supportive departments throughout the
hospital (CVCC; CVP diagnostics; Radiology/CT; Pre-
By Sept 1, 2012 a coordinator was recruited (Susan
op testing; Surgery Care Center; Cath. lab staff; OR
Wodarz, RN, BSN) and patients identified with severe
staff; CVPACU staff; CV3 Staff)
aortic stenosis were seen in a clinic space on the
Cardiovascular Care Center (CVCC) one Tuesday
The high quality outcomes of the TAVR patients are
per month. An Average of 5 patients seen per month
due to the entire team of health care professionals
were seen within the first few months. In November
(Physicians, Nurses, and Techs.) at University Hospital
of 2012 the indication for patients considered High
doing what they all do best!
Continuing Professional Development
Certification Annually, our nursing staff recognizes those
differential for certified nurses. In late 2013,
among them who have taken the added step to
our certified nurses got a new resource to help
demonstrate excellence through achieving national
them maintain their credentials when University
certification. In 2013 and 2014, we recognized
subscribed to the EBSCO Nursing Reference
significant gains in the number of nurses with this
Center. Suddenly our nurses gained access to
distinction â&#x20AC;&#x201D; an increase of approximately
hundreds of evidence-based continuing education
59 percent between 2012 and 2014.
programs, in addition to the many other resources incorporated in this resource. We anticipate that
Our efforts to promote certification amongst
having this resource available to our staff at point-
our nursing staff include hosting certification
of-care and from their personal computers will
prep courses, peer-to-peer encouragement,
enhance their ability to earn the necessary CE to
examination fee reimbursement, and an hourly
support their maintenance of certification.
Academic Continuing Professional Development
ED Fellowship Launched Nursing retention is a major issue for hospitals and providing an effective transition from the academic setting to the hospital setting is filled by both excitement and apprehension for the
In December 2010, the landmark IOM Future
graduate nurse. In 2014, the ED
of Nursing report was released. One of the
director sought opportunities to improve
recommendations made was to increase the
the transition of graduate nurses into
proportion of nurses at the baccalaureate or
the ED. The ED clinical educator,
higher level to 80 percent by the year 2020.
Denise Simon, BSN, CEN developed
At University, we have made a commitment to
a 13-week Emergency Department
pursue the 80 percent by 2020 goal, focusing
Fellowship Program for graduate nurses,
on our staff nurses. A number of resources are
incorporating the Emergency Nurses
in place to support academic advancement by
Association (ENA) online orientation
our nurses, including tuition reimbursement,
course which covers a broad scope of
scholarships, and organization partnerships with
practice to deliver quality urgent and
academic nursing programs. In 2014, during a
complex care for patients across the
major hiring initiative, we instituted a requirement
lifespan as part of an orientation plan.
that newly hired non-BSN prepared nurses
The Fellowship, launched April 2014,
commit to obtaining the degree within 4 years.
consists of orientation time, clinical
This move will enhance the success we have
lectures and the ENA course. In 2014, 17
already achieved. Between 2011 and mid-2014,
graduate nurses successfully completed
we increased the percentage of staff nurses with
the Fellowship, which was offered three
baccalaureates from 50.1 to 58.4 percent -- an
times.
increase of almost 17 percent in three years!
Evidence Based Decisions
Evidence-based decision-making is employed
EARLY ELECTIVE DELIVERIES
throughout our facility and the nursing staff. UH has a number of resources in-place to support this,
Early elective deliveries (between 37 and 39
including online resources readily-available, such
completed weeks of gestation) have increased
as the EBSCO nursing reference center and the
dramatically in the years 1990-2006 and the US
cadre of clinical nurse educators.
CVPACU Blood Filterâ&#x20AC;&#x201D;Evidence Based Care CVPACU staff nurses Sandee Daust and Robin Slagle asked the question: Why do we double filter blood when administering packed red blood cells (RBCs)?
labor induction rate more than doubled during this period, from 9.5 to 22.5 percent, while the cesarean rate grew to a high of 32 percent. The increase is rates is likely due to a number of factors, including: incorrect patient belief that it is safe to deliver as early as 36 weeks, culture in hospitals, and fee for
While we had done this for at least 25 years, no one,
service payment models. A recent review of the
including our cardiothoracic surgeons, remembered
literature identified the negative consequences
why it was originally ordered in that way. Sandee
possible for mother and babies. Women and babies
and Robin implemented an evidence-based practice
where the mother is induced at the 37th-38th week
project to examine the available evidence and
have significantly higher risk of having cesarean
literature to determine whether double-filtering of
section, postpartum complications, neonatal
packed RBCs was necessary in open heart surgery
mortality and morbidity, and babyâ&#x20AC;&#x2122;s placement in
patients and considered a cost analysis of the Pall
the NICU. Both maternal and neonatal lengths of
filters used in CVPACU. Finding no literature to support the practice of double-filtering the blood, they took the question to Universityâ&#x20AC;&#x2122;s Microbiology and Lab Manager, who assured them that all blood administered at University is leukocyte washed, negating the need
stay also increase with either elective induction or elective cesarean section. An interdisciplinary committee involving physicians, clinical educators, clinical nurse director, nurse managers, and later unit clerks, assistant nurse
for double filtering. Further, it was determined that
managers and nursing staff. They set a goal in L&D to
there would be significant savings in eliminating the
decrease EEDs to zero, or less than 5 percent which is
un-necessary practice. The annualized cost savings
one of the core measures as a shift in culture towards
from eliminating the extra filter was $3,500 and there
evidence-based care.
would be further savings in nursing time. Thus, it was a win-win for all when a new practice standard was
The committee established an algorithm of when and
approved in 2013, eliminating this needless step.
how to receive inductions in the OR as well as L&D for
This one project depicts the role of University Nurses in promoting evidence-based practice and properly using technological advancements, components of our nursing practice model. The reliance on evidence and cost-savings to the organization support the Nursing and Organization strategic plans.
the unit clerks. A Hard Stop was initiated September 25, 2013. We have a significant decrease. The rate had decreased to 6.3 percent in December 2013 and 3.1 percent in December 2014.
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