2015 Kenmore Mercy Nursing Annual Report

2015 Annual NURSING REPORT Improved Patient & Family Outcomes Mutually Established Goals Collaboration

Healthy Work Environment

Integrity

Faith - Based

Innovation

Professional

Development

Communication

Relationship Building/Therapeutic Conversations/Empathy

Nursing Professionalism Caring / Knowledge / Evidence-

Based Practices / Advocacy / Compassion / Trust-

Nursing’s Foundational Components

Worthiness

Table of Contents

A Message From the CEO Dear dedicated nursing team,

Leadership Messages 2

3

When I look back at the last year, I see that significant progress was made on our journey toward nursing excellence.

Message from James M. Millard, President & CEO Message from Cheryl W. Hayes, Vice President of Patient Care Services

Transformational Leadership 4 4 5 5 6 6 7 7

Surgical Services Updates Beacon Award Heart Failure and Stroke Awards Joint Commission Gold Seal Musculoskeletal Symposium ED Pivot Nurse Research Conference Patient Portal

James M. Millard

You helped us achieve excellent patient outcomes, innovated new practices, created a safe care environment, and advanced the professional practice of nursing - all while living our Catholic Health values of reverence, compassion, justice, and excellence.

Structural Empowerment 8 9 9 10 10 11 11 12 12 12 13

Outstanding Nursing Associates DAISY Award Nursing Professionalism Essays CNOR Certification Food Trucks Wedding Bells Ring in MRU LOVE Award Meeting Community Needs Educating Local Students Medical Staff Associate of the Year Mission Trips

In this report, you’ll read about some of our nursing team’s most notable achievements from the past year. You’ll also read about their positive impacts on our patients, community, organization, and the nursing profession.

This includes significant reduction of pressure ulcers, improvement of our central line-associated blood stream infection (CLABSI) rates, introducing the Nursing Professional Practice Model, and receiving the Beacon Award.

Exemplary Professional Practice 14 15 15 16 16 17 18 19

Nursing Professional Model FAST Team Flexible Scheduling Advance Directive Preparation GI Fair Certifications Foundation Funding Move with Care

New Knowledge, Innovations, & Improvements 20 21

Throughout this journey, you have continued to show a commitment to continually improving and evolving as necessary to meet the ever-changing demands of our industry and patients.

We also continued our work to prepare for Magnet designation.

That process has been challenging but satisfying as we take inventory of our professional nursing accomplishments.

I’m proud of all that our nursing team have achieved in the past year. When I think about our journey toward excellence, I am confident that we are well on our way.

It is an honor to work with you. Thanks for all you do to deliver the best care for every patient, every family, every day.

Sincerely,

Bed Ahead Pressure Ulcer Rates

Empirical Outcomes 22 23

Patient Experience Infection Rates

Editorial Staff

Dawn M. Cwierley, AS, BS Cheryl W. Hayes, MS, ANP, NEA-BC Kathleen Vitthuhn, RN, MSN, NE-BC

James M. Millard, R.Ph. President & Chief Executive Officer

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A Message From the Vice President of Patient Care Services Dear friends and colleagues,

“As a nurse we have the opportunity to heal the heart, mind and soul of our patients, their families and ourselves. They may forget your name, but they will never forget how you made them feel.” ~ Maya Angelo

Cheryl W. Hayes

I believe that this quote is fundamental to the heart of nursing. You each start life with the choice of a boundless number of professions, however, you chose nursing. For many of you those words Maya Angelo so eloquently wrote are the very reason that you chose this field of caring.

Below is a just sampling of real patient quotes collected over the years. These are true testaments of our how you as nursing staff make our patients feel as they commit their trust to you during their time of need.

• • • • •

“I think the nurses were wonderful and kind.”

“The nurses and nurse’s aides were wonderful, respectful as well as compassionate during my recovery.”

“The Emergency Department’s nurses listened to me and gave me excellent care.”

“The care provided by the nurse was uniformly of high quality, capable, polite, courteous and personable.”

“I must tell you that I have never been at a facility with such kindness, compassion and professionalism as I experienced at Kenmore Mercy Hospital.”

• “The nurses and nurse’s aides were amazing.”

• “I was treated with kindness and courtesy.”

• ‘We were blessed by our nurse’s attentiveness, as well as her presence.”

Our 2015 Nursing Annual Report highlights the accomplishments of you, our generous and talented nursing staff.

Throughout this report, you will learn about our patient and associate safety strategies, staff-implemented community outreach programs, and process improvements, as well as nursing education and development.

I hope you enjoy this report and are as inspired as I am for what the future holds for Kenmore Mercy Hospital. You have many accomplishments over this past year to be proud as we continue our journey to nursing excellence.

Sincerely,

Cheryl W. Hayes, MS, ANP, NEA-BC Vice President of Patient Care Services

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Transformational Leadership Transforming The Face of Surgical Services One Step at a Time With growth in surgeries and changing technology placing pressure on Kenmore Mercy’s surgical space, a multi-phase plan was initiated to transform the Surgical Services Department.

In the last few years, this has included the addition of two new state-of-art surgical suites, renovation of the Sterile Processing Department, and facelifts to the Pre-Surgical Testing Department.

In 2016, the hospital unveils its newest addition, a new Ambulatory Surgery Unit. The final phase of the project will be the completion of the Post Anesthesia Care Unit the summer of 2016. When the project is complete, the hospital will have invested more than $10.5 million into transforming surgical services.

Ambulatory surgery nurses JoAnne Luciani, Margy Donofrio,

“The renovations are part of the hospital’s plan to enhance patient Maureen Mycek and Susan Kirsch, look forward to their new services, increase efficiencies, and improve access to surgical services,” patient care space. said Margy Donofrio, BSN, RN, CNML, CAPA, nurse manager of the Ambulatory Surgery Unit, Post Anesthesia Care Unit, and Pre-Surgical Testing.

The ASU staff was very involved in this project, attending planning and construction meetings, and even providing input on décor, placement of computers, mounting of blood pressure cuffs, and much more. Nurses also functioned as team leaders to ensure a smooth transition with patient flow process, supplies, equipment, and safety.

ICU Receives Beacon Award for Critical Care Excellence Kenmore Mercy’s Intensive Care Unit was granted the Beacon Award for Excellence - Silver Level, for exceptional nursing and patient care in the critical care setting. Created by the American Association of Critical-Care Nurses (AACN), the award is intended to recognize individual units that distinguish themselves by improving every facet of patient care. Documentation for this award was submitted in summer 2015.

The award is given for a three-year period at gold, silver and bronze levels.

Kenmore Mercy Hospital has maintained its silver status for two consecutive periods. The ICU associates are already working on their goal to receive gold status during the next cycle.

”As a bedside critical care nurse, I am very proud we have received the Beacon Silver Award. We are blessed with an outstanding interprofessional team within our unit. I feel each and every individual on our team is a champion of care, contributing and promoting the standards of excellence The Beacon Award represents of the work of multiple disciplines. Cheryl Hayes, Mary LaMarthis award denotes,” said Mary LaMartina, BSN, RN, CCRN.

tina, Kristen Parisi, Brenda Queeno, Karen Duerr, Chris Dowd, and Kristyn Durick, accepted the award.

Beacon criteria include: leadership structures and systems; appropriate staffing and staff engagement; effective communication; knowledge management and best practices; evidence-based practice and processes; and patient outcomes, according to the AACN.

According to the AACN’s website, there are only 18 hospitals in New York State that have received the Beacon Award, and Kenmore Mercy Hospital is the only one in the Buffalo area and surrounding counties.

“We are committed to working together, and across other disciplines, to achieve evidence-based practice in patient care, training, mentoring, recruitment and retention at Kenmore Mercy Hospital, for the best possible outcomes for our patients,” said Kristen Parisi, BSN, RN, CCRN, nurse manager for the Intensive Care Unit. “I am extremely proud of our entire ICU staff for their continuous dedication to our patients, and each other.”

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Hospital Awarded for Heart Failure and Stroke Efforts Kenmore Mercy Hospital received the Gold Plus Heart Failure Award and Gold Plus Stroke Award from the American Heart Association under the “Get With The Guidelines®” quality improvement initiative. These awards honor hospitals that have met or exceeded the AHA’s specific guidelines for providing outstanding care in different categories.

The hospital was also recognized as a recipient of the Association’s Target: Heart Failure Honor Roll, for improving patient care and reducing hospital readmissions.

This marks the third year that Kenmore Mercy Hospital has been recognized with a quality achievement award for its congestive heart failure program, having previously received the Gold Plus Award in both 2014 and 2015 and the Silver Plus Award in 2013.

This is also the third year the hospital has been recognized with the Stroke Gold Plus Award.

The work of staff from the 3 East Patient Care Unit significantly helped in the hospital earning the heart failure recognition.

“Heart failure and stroke are two very critical health concerns, and we proactively looking for ways to turn treatment guidelines into lifelines for our patients,” noted Amy Baker, BSN, RN, stroke program coordinator and acting cardiac clinical advisor. “We are especially proud of the work that our staff has done to support our heart failure and stroke patients after discharge, thus decreasing readmissions and improving length-of-stay and reduction in mortality rates.”

To earn the Gold Plus Heart Failure Award, Kenmore Mercy Hospital met specific measures for the diagnosis and treatment of heart failure patients at a set level for a designated period. These measures include proper use of medications and aggressive risk-reduction therapies, such as cholesterol-lowering drugs, beta-blockers, ACE inhibitors, aspirin, diuretics and anticoagulants while patients are in the hospital.

Before patients are discharged, they also received education on managing their heart failure and overall health, as well as referrals for cardiac rehabilitation.

To earn the Gold Plus Stroke Award, Kenmore Mercy Hospital met specific criteria including aggressive use of medications and risk-reduction therapies aimed at reducing death and disability and improving the lives of stroke patients.

Kenmore Mercy Earns Third Consecutive Gold Seal of Approval In the fall of 2015, Kenmore Mercy Hospital’s Knee & Hip Center earned The Joint Commission’s Gold Seal of Approval® from The Joint Commission as a certified center of excellence; it was also awarded Advanced Certification as a Primary Stroke Center.

During on-site reviews, Joint Commission experts evaluated the hospital for compliance with standards of care specific to the needs of patients and families, including infection prevention and control, leadership and medication management.

To earn these distinctions, the disease management program undergoes an extensive, on-site evaluation by a team of Joint Commission reviewers every two years.

“With these Joint Commission certifications, we are making significant investments in quality on a day-to-day basis from the top down,” said Laura Verbanic, PT, BB, CPHQ, director of Quality & Patient Experience.

Preparing for certification is a demanding process for the nursing team. Kenmore Mercy is the first and only hospital in Western New York to earn both the knee and hip distinctions since it was first certified in 2011.

The Joint Commission’s site survey commended Kenmore Mercy’s knee and hip joint replacement programs in a number of areas, including the hospital’s interdisciplinary team’s collaborative approach to providing the best care to patients and its comprehensive associate education program, which prepares both clinical and non-clinical staff on how to care for orthopedic patients.

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Associates Present at Musculoskeletal Symposium Kenmore Mercy was a shining star at the community outreach event - A Multidisciplinary Approach to the Musculoskeletal System - on November 14. More than a third of the presenters were associates and medical staff hailing from the hospital.

Kenmore Mercy Hospital nurse presenters included Alan Chittley, ONC, RN; Elizabeth LoFaso, BSN, MSEd, RN, ONC; and Deb Micholas, BSN, RN, ONC.

Other presenters from the hospital included Deborah Bedard, PT; Beth Anne Rutter, PT; Rev. Nancy Faery, MDIV, BCC; Brenda V. Queeno, PharmD; Marcus Romanowski, MD; and Matthew Mann, MD.

Widely attended, with nearly 150 guests, the symposium was a comprehensive review of the important aspects of orthopedic and spine protocols for physicians, therapists and nurses.

Registered nurse Alan Chittley worked with

A few of the topics covered by Kenmore Mercy associates included early mobility a multidisciplinary group to present about for total joint patients; fundamentals of ankle replacement; and multimodal pain pain management. management using a multidisciplinary approach.

Process Redesign Helps ED Exceed Throughput Goals More and more people are seeking care in emergency departments (ED), leading to crowding and extended wait times that can adversely impact patient satisfaction and outcomes.

Faced with this challenge in its own fast paced ED, Kenmore Mercy Hospital added a “pivot nurse” position in 2015.

The pivot nurse is the first member of the Emergency Department team that a patient meets. Their role is to quickly determine, within 20 minutes of arrival, whether or not the patient needs immediate intervention.

ED Door to ESI Triage % within 20 Minutes 120

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100 80

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70

99

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98

70

60 40 20

In order to assure that each patient is seen according to the type and urgency of their conditions, an initial screening is performed by this trained clinical nurse using the Emergency Severity Index (ESI), an evidenced based five level triage tool, to prioritize and identify those individuals that need to receive priority attention.

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The nurse performs a brief, focused assessment and assigns the patient a triage acuity level, which represents a measurement of how long the patient can safely wait for further medical screening examination and treatment.

The new role was developed by Heather Telford, MS, RN, CEN, director of Critical Care Nursing, and Amanda Kramer, BSN, RN, CEN, nurse manager of the Emergency Department, in collaboration with ED nurses and an interdisciplinary team.

“The ED nurses played an integral role in the success of implementation initiative,” noted Amanda.

The nursing team was part of a work group who reviewed the triage process and decided that an additional nurse resource, the “pivot nurse,” would need to be introduced to the triage process. They also made recommendations regarding staff resources, supplies, and where the “pivot nurse” would be located.

The implementation of the “pivot nurse” in the ED has successfully increased the percentage of patients with an ESI completed within 20 minutes of arrival. With the addition of the new role, the ED was also better able to decrease the number of patients who were leaving without being seen.

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Nursing Presents at Research Conference The Kenmore Mercy Hospital nursing team presented four research posters at the 28th Annual Nursing Research & Scholarly Activities Conference in April 2015.

The night long event, sponsored by the Professional Nurses Association of Western New York and the Nursing Honor Society “Sigma Theta Tau International” (Gamma Kappa, Gamma Theta and Zeta Nu chapters), brought together nursing colleagues from across the Buffalo area to share their contributions.

The four Kenmore Mercy research projects included: the Medical Rehabilitation Unit’s “STOP Light” fall prevention program, the Intensive Care Unit’s ABCDE Bundle, the Palliative Care Committee’s Champions Program and the Emergency Department’s tPa and ACE inhibitors case study.

Registered nurses Christine Schwinn, Mary Jane Lodico, and

The ABCDE Bundle, implemented by the ICU last year, follows Mary Whelan, presented regarding the STOP Light program. national critical care guidelines to help get the hospital’s sickest patients up and moving, and off the ventilator quicker.

The Palliative Care committee’s program, titled “Effectiveness of a Unit Based Palliative Care Champions Program,” was developed to improve the quality of life of patients who might benefit from inclusion in the outpatient palliative care program.

The Emergency Department’s case study reviewed the relationship between tPa and ACE Inhibitors and the potential for developing the life threatening airway condition of orolingual edema.

The posters were very well received with many requests for more information on the studies and how to start these projects in other settings.

Patient Portal Helping Patients Get a Closer Look

Catholic Health introduced a new online tool - Catholic Health Connect - to help patients stay connected to their health information in 2015. This secure online patient portal allows patients to access information from their medical records, wherever and whenever they need it.

Nursing actively promoted Catholic Health Connect to patients and families, helping them to better understand and manage their health.

“Keeping patients healthy means keeping them engaged, and that requires access to their health information,” said Brian D’Arcy, MD, senior vice president, Medical Affairs for Catholic Health.

Catholic Health Connect provides access to medical information gathered and recorded from both inpatient and outpatient visits to Catholic Health facilities. It includes lab and diagnostic imaging results, discharge instructions, medication information, and a wide range of health education information.

Catholic Health Connect users can also send secure email messages directly to Catholic Health’s Health Information Management Department (Medical Records) to request additional information that may not be available on the portal.

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Structural Empowerment Outstanding Associates Honored During Nurses’ Week Nurses Week, May 6-12, is the time each year for celebrating the vital role all nurses have in communities spanning the U.S. In 2015, this included three special individuals at Kenmore Mercy who were recognized for their caring and nurturing spirit.

2015 Nurse of Distinction

Jessica Klug, BSN, RN, began her career at Kenmore Mercy Hospital as a medical-surgical nurse on the 2 West Patient Care Unit in the fall of 2012. She most recently earned a Bachelor of Science in Nursing from the State University of New York at Brockport. Jessica has emerged as a leader among her peers, acting as a preceptor and serving on multiple committees, including the Shared Governance Practice Council, to contribute to patient care, satisfaction and safety. As a member of the American Medical Surgical Nursing and Professional Nurses Association of Western New York, she fosters a positive public image of nursing. While a nursing student, she published an article on frontotemporal dementia in the August edition of Nursing2014, a well-known national nursing journal.

Jessica Klug

2015 Outstanding Staff Nurse

Kathryn Scribner, BSN, RN, joined Kenmore Mercy Hospital in 1982. She currently works in the hospital’s Knee & Hip Center and on the 2 East Patient Care Unit where she cares for patients following surgery. Her attention to details, questioning attitude, and sensitivity to patients has earned her the respect of her peers. She places a high priority on patient safety and customer service.

2015 Outstanding Nursing Attendant

Nancy Gargas, NA, started her career at Kenmore Mercy Hospital in 1985. She began in the Surgical Department, prior to moving to the Post Anesthesia Care Unit where she has worked ever since. Her nomination notes that she, “puts our patients first, has a positive attitude, and is always willing to help.”

Kathryn Scribner

“Our nursing staff is the backbone of our hospital system; the link between the patient and family, the physician and the organization,” said Cheryl Hayes, MS, ANP, NEA-BC, vice president of Patient Care Services.

Nancy Gargas

Caroline Sweeney, Marsha Cleland, and Barb Kanaley serve patients in the Pre-Admission Testing Department.

Scott Berube, Suzanne Hartl, Pamela Farrell, Nancy Gargas, and Rene Marriott care for patients in the Post Anesthesia Care Unit.

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Two Nurses Receive DAISY Award in 2015 Kenmore Mercy’s Nursing Department recognized two amazing nurses in 2015 with the DAISY Award, which celebrates the uniqueness and values of our nurses.

Congratulations to Melissa Cavalluzzo, RN, from 2 East/2 South, and Tracey Meinhart, RN, from Surgical Services.

The DAISY Award honors nurses who go “Above and Beyond” and those who define patient/family centered care.

Healthcare organizations partner with the DAISY Foundation to provide this award to nurses who are nominated by patients, families or co-workers. The “blinded” nominations are reviewed and selected at Committee Day by nursing peers.

The DAISY Award was founded by the family of J. Patrick Barnes who passed away at the age of 33 after battling Idiopathic Thrombocytopenia Purpura. After his death Patrick’s family set up the DAISY Foundation to say thank you to nurses everywhere for all that they do for their patients.

Tracey Meinhart (right) was nominated by Dr. Ross Sherban, here with Anne Hedges-Creighton.

Cheryl Hayes and Mary Hojnacki presented Melissa Cavalluzzo (center) with her award.

Nurses Address Professionalism in Essays What does nursing professionalism mean to you? Registered nurses Kristyn Durick, Intensive Care Unit; Alan Chittley, 2 East/2 South; and Mary Willis, 3 East, answered that question as part of a Nurse Practice Committee essay contest.

Kristyn, who was awarded first place by her peers, noted in her essay that, “Nurses have proficient knowledge, moral standards, good communication skills, kindness, respect for all people, and a remarkable attitude toward selfless care.”

She added, “Respecting your patients, families, colleagues and ancillary staff is a large part of professionalism. Communicating effectively is a large part of how we exemplify respect. A professional nurse speaks clearly and directly to people.”

Heather Telford, Kathy Vitthuhn, and Kristen Parisi, congratulate Kristyn Durick (right center).

Alan, who was awarded second prize, noted in his essay, “Professionalism is also shaped by why we chose this profession. If we chose just to get paid, and an end to a means for money, then that is all the profession will mean to that person. But if we chose as a means to help others with our God given skills, and desire to do our best for the patient and be pleasing to God, then we will enter the realm of being a professional nurse.”

Last, but not least, Mary, was awarded third prize. In her essay she noted, “Professionalism in nursing, to me, begins in the heart and the mind of a nurse. Once you have passed your boards to practice as a registered nurse that does not automatically make you a professional. Professionalism is a choice that can make a profound impact on patient care and job satisfaction. It also creates a healthy work environment.”

Thank you to all of the nursing staff who participated in this essay contest.

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CNOR Certification Training Promotes Leadership In the OR When nurses obtain a certification, they expand their knowledge base, grow within their field and evolve as professional. In the case of the credential of Certified Nurse Operating Room or CNOR, it acknowledges a nurses commitment to the highest standards of patient care as well as validates the specialized perioperative skills, experience and knowledge he or she has attained.

In 2015, Kenmore Mercy Hospital had only two nurses with CNOR certification, Rachel Achtziger, BSN, RN, from Surgery, and Linda Butski, BSN, RN, nurse manager of the Surgery/Endoscopy Unit. Kenmore Mercy’s Perioperative leadership hopes to see that number rise in 2016.

To help move in that direction, they sought out the assistance of Catholic Health’s Clinical Education Department, who in November of 2015, in collaboration with Erie County Medical Center and Kaleida Health, partnered to bring Med-Ed Seminars to Buffalo. This included a two-day CNOR certification program held at the Administrative Regional Training Center to prepare nurses for the rigorous national exam.

“Patient safety and positive surgical outcomes are of the utmost importance to us and research shows that nurses who earn the CNOR credential have greater confidence in their clinical practice and in promoting improved patient outcomes,” stated Anne Creighton-Hedges, BSN, MS, RN, Kenmore Mercy’s director of Nursing, Perioperative Services.

The CNOR certification program is for perioperative nurses interested in improving and validating their knowledge and skills and providing the highest quality care to their patients.

For more than 30 years, perioperative nurses have used the CNOR credential to gain credibility and recognition from colleagues and patients, achieve their personal and professional goals, and enhance their career development.

CNOR credentialing represents a level of professional achievement and a demonstrated knowledge of clinical competence and practice standards. Becoming certified as a CNOR portrays nurses as leaders and role models in the healthcare community as well as stewards for the operating room professional community. This credential reflects a deep personal commitment to the care of their patients.

Food Trucks Drive Community Building

One of the biggest trends across the nation in dining over the last few years has been food trucks. Kenmore Mercy Hospital jumped in on this phenomenon in 2015, adding weekly visits from local restaurants on wheels throughout the summer, serving up everything from thick specialty grilled cheese sandwiches to sizzling and savory tacos.

A result of Emergency Department Shared Governance, the food trucks were an associate satisfier across all of Kenmore Mercy Hospital.

“The food trucks gave staff the opportunity to get off their units and go outside for a while,” noted Amanda Kramer, BSN, RN, CEN.

“It encouraged associates to take a few peaceful moments outside to enjoy the fresh air, something that many nurses do not prioritize enough for themselves,” she added.

Nurses Cheryl Robinson and Jean Wood enjoyed stepping out each week to try a new treat from the food truck vendors.

The hospital’s neighbors also looked forward to seeing which truck would be stopping by. Some favorites included Chef’s, Lloyd’s Taco Truck, 716 Club House, and J & L BBQ Food Truck.

“The food trucks were a great success,” said Jean Wood, BSN, RN, Emergency Department. She was behind the scenes each week planning the various vendors and working in collaboration with Administrative and Security Departments.

“Staff can’t wait for the 2016 line up,” added Jean.

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Wedding Bells Ring in MRU The Medical Rehabilitation Unit’s nursing team at Kenmore Mercy Hospital took the patient experience to a new level on September 26. They helped to ensure a stroke patient could participate in her daughter’s wedding.

Upon hearing Judith Boris’ story, the nursing staff got working to ensure she could celebrate with her family.

In less than 48 hours, plans were in place for her to share in her daughter’s special day at Kenmore Mercy Hospital. Registered nurse Mary Jane Lodico, made arrangements so Judith could watch daughter Dawn Boris and son-in-law Eric Saldanha’s planned ceremony at St. Joseph University Parish via Facetime with nursing and medical staff close by.

Following the emotional ceremony, Judith’s family joined her in Kenmore Mercy Hospital’s beautiful chapel for photos. Thanks to Mary Jane and nurse attendant Denise Chatt, she was dressed for the occasion and her hair and makeup done.

Nursing attendant Denise Chatt helped get Judith ready for the big day.

Nurse manager Christine Schwinn, BSN, RN, also made arrangements for a small reception. Christine was proud of her staff’s actions. “What a blessing it was for our team to be part of this special day for Judith and her family. We go out of our way for our patients every day.”

“This wedding was just one more way that our staff demonstrated their dedication to Kenmore Mercy Hospital’s mission and values,” she said.

Later in the year, the Medical Rehabilitation Unit was nominated with the LOVE Award. A special recognition was presented to the entire team for exceptional commitment to the mission, exemplified through their creativity in helping Judith.

Nursing Staff Honors Our Values Congratulations to the nursing staff who received LOVE Awards in 2015. Katherine McCann, unit clerk on the 2 East and 2 South Patient Care Units, received the 2015 LOVE Award for first quarter of 2015. Float pool unit clerk Khaled BenSalem was recognized as the LOVE Award recipient for the 2015 - 4th Quarter.

Their nominations speak volumes about their commitment to Kenmore Mercy’s mission and values. In Katherine’s nomination, it stated that she, “is so patient and kind to all who are lucky enough to know her.” Khaled’s nomination noted that he is, “Loving and compassionate. His empathy for people is unlike anything I have seen from others. He is not afraid to share his heart.”

The LOVE Award is designed to recognize employees who demonstrate our values reverence, compassion, justice, and excellence - in their daily work. Anyone can nominate an associate for the LOVE Award – patients, visitors, family members, physicians, volunteers and co-workers.

Katherine McCann celebrated her award with her colleagues, including nurse manager Mary Hojnacki.

Khaled BenSalem was presented the LOVE Award by Joseph Mazzawi, vice president of Mission Integration.

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Nursing Helping Fulfill Community Needs The nursing staff at Kenmore Mercy Hospital give of themselves every day and do so by living our values of reverence, compassion, excellence, and justice. In 2015, they showed these values in a number of ways that go above and beyond.

One example is their involvement in the annual Thanksgiving basket collection that benefits families in the Ken-Ton area.

This past year, 45 baskets were distributed by local parishes, including: St. Timothy’s Roman Catholic Church, Knox Presbyterian Church, Faith United Presbyterian Church, New Covenant Tabernacle, Kenmore United Methodist Church, St. Amelia’s Roman Catholic Church, St. Paul’s Roman Catholic Church, and St. John the Baptist.

At Christmastime, the nursing departments purchased Staff from the Ken-Ton Primary Care and Pulmonary Rehabilitation offices gifts for “adopted” families. The overwhelming joy of helped gather gifts for local families. these families was an unforgettable memory for everyone involved.

Unfortunately, the need for food and other necessities goes beyond our neighboring community, which is why Catholic Health has established a relationship with Friends of Night People, which helps the poor, homeless and destitute in Buffalo.

Throughout the year, Kenmore Mercy Hospital’s nursing team and other associates have helped by collecting food and clothing, as well as by lending support in the non-profit’s pantry and soup kitchen.

Thank you everyone who continues to live our mission by giving to others.

Surgery Staff Educates Local Students

Students from Sacred Heart High School got a behind the scenes look at the medical industry in August during a tour of Kenmore Mercy Hospital.

It’s part of Catholic Health’s MASH Camp, which stands for Medical Academy of Science and Health. The program gives students the opportunity to meet with working health professionals, participate in handson demonstrations, and tour various departments within the hospital, to see if a future career in healthcare might be right for them.

Linda Butski, BSN, RN, nurse manager of Surgery/Endoscopy Unit, (pictured to the right) took the students on a tour of the surgical services where they spent time in one of the hospital’s new operating rooms.

Associates Recognized by Medical Staff

Physicians at Kenmore Mercy Hospital recognized Helen Rovillo, unit clerk from 2 West, and Brian Wetzel, Pharm.D., (pictured to the right) who received the Annual Medical Staff Associate of the Year Award for 2015.

This award recognizes outstanding associates for their service to patients and staff.

“These are individuals whose hard work and dedication represent the spirit of Kenmore Mercy Hospital,” said Michael Gough, DO, who presented the awards on behalf of the medical staff.

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Associates Put Skills To Use During Mission Trips Thousands of miles away from the comforts of home, Kenmore Mercy Hospital associates are making a difference to individuals in desperate need of their help. Over the past year, several nursing staff members took part in medical mission trips.

Registered nurses from Kenmore Mercy’s Surgery Department — Janice Vosburgh, Jacob Walck, and Rachael Achtziger — as well as David Vogt, MD, anesthesiologist, traveled to Santo Domingo in the Dominican Republic in March as part of a World Spine Outreach mission trip.

They were among 28 volunteers from throughout the United States who screened 35 scoliosis patients. Of them, 24 children received corrective scoliosis surgeries. Others had comorbities that prevented surgery from taking place.

“This is how I leave my stamp on the world,” said Janice, who is the founder of the World Spine Outreach. “I am helping children who would die otherwise.”

Gena Long, RN, from the 2 East and 2 South Patient Care Units, had the opportunity to travel to Delmas 75, Port au Prince, Haiti, as part of a medical mission trip in July.

This area was devastated in 2010 by a 7.0 earthquake that destroyed much of the central historic area. After the earthquake, only two hospitals remained that were operational.

While there, she, along with other medical professionals, treated people of all ages, most of which were women and children, with mumps, chicken pox, various skin rashes and anemia.

“There were some sicknesses and disorders that could not be treated, but everyone was seen and cared for to the best of our ability and capability with the means that we had,” said Gena.

Most patients were given medications, vitamins and creams. Some were given reading glasses and toothbrushes. Prayers were given to anyone who requested.

Medical missionaries are responsible for their own airfare. Many of them host fundraisers and seek donations, money, goods for the trip, including medical supplies, toys, and clothes to be distributed to the locals.

They travel with very little personal belongings, instead packing necessary medication and medical equipment.

Medical mission trips are just one more way that Kenmore Mercy Hospital associates continue to live our mission to provide the healing love of Jesus to those in need.

This was the first mission trip for Jacob Walck, pictured here with a volunteer from Salt Lake City.

Gena says her trip was a very rewarding experience. She had the opportunity to expand her nursing skills and treat both pediatric and adult patients.

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Exemplary Professional Practice New Model Guiding Nursing Practice Six months after Kenmore Mercy Hospital nurses and clinical staff formally committed to achieving Magnet designation through the application process, the group took the next step toward excellence by unveiling a Nursing Professional Practice Model (PPM). Staff received their first glimpse of the new model during the Associate Forum sessions in October 2015.

Designed by clinical nurses, the Professional Practice Model schematically depicts how nurses at Kenmore Mercy Hospital deliver patient-centered care, serves as a visual representation of nursing practice, and represents the professional commitment to our patients and their families.

Nursing is represented as the first step as the foundation of the model (the groundwork that supports the structure). The second step represents the concepts the clinical nurses feel embody nursing professionalism at Kenmore Mercy Hospital.

“The pillars of our nursing practice are labeled with the characteristics the clinical nurses feel are the most important that we carry out in our professional practice,” said Amber Mazurek, BSN, BS, RN, ONC, patient care services project advisor.

Cheryl Hayes presented the new nursing model during the Associate Forum sessions in October.

Each pillar embodies what nursing practices each and every day. They, in turn, act as a support system for building relationships with our patients, families, and inter-professionally.

Nursing utilizes these characteristics to aid in obtaining mutually established goals with our patients. Improved patient and family outcomes are represented at the peak, because the care of patients is our top priority. Positive outcomes for our patients was identified by our clinical nurses as what we strive for every day.

Cheryl Hayes, MS, ANP, NEA-BC, vice president of Patient Care Services, has been supportive of Kenmore Mercy’s Magnet nursing process and how it is elevating nursing excellence.

“Creating Kenmore Mercy’s Nursing Professional Practice Model solidifies our commitment to nursing excellence and providing quality care to our patients. As we move forward on our Magnet journey, I continue to be humbled by the amazing work our nurses do every day,” she said.

Improved Patient & Family Outcomes

Mutually Established Goals Collaboration

Healthy Work Environment

Integrity

Faith - Based

Innovation

Professional

Development

Communication

Relationship Building/Therapeutic Conversations/Empathy

Nursing Professionalism Caring / Knowledge / Evidence-

Based Practices / Advocacy / Compassion / Trust-

Nursing’s Foundational Components Nursing’s Foundational Components 2015 Nursing Annual Report

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Worthiness

Providing Safe, Quality Care with FAST Results Providing safe, quality care is our top priority at Kenmore Mercy Hospital. That’s why nursing has created the Family Assistance and Support Team (FAST). The team helps provide families with extra help in the hospital when they have concerns about a patient’s care.

Associates are encouraged to try to resolve issues when they hear about them, but when that isn’t possible, the FAST team is activated. Reasons may include being concerned that the medical team is not recognizing or addressing a change related to a medical condition or experiencing problems with the way care is being given, such as confusion about treatment and what needs to be done.

“Our goal is to improve communication between patients, families and hospital staff,” noted Kathy Kanaley, patient representative. “We want to address concerns at the earliest possible opportunity.”

Flexible Scheduling Boosts Nurse Morale, Retention The nursing profession is one that requires 24 hour per day coverage. It can be challenging for staff to maintain a balance of work and home life, especially on the “off shifts.” Based on staff feedback to have more control over their own schedule, Kenmore Mercy Hospital developed a protocol for allowing the staff to self-schedule themselves.

Prior to this implementation, scheduling was done by the manager of each individual unit. Schedules were based on the requests off what staff submitted, and as the unit needs required. Staff would see their final schedule when it was posted and could then make switches.

Following a review of various alternatives, nursing leadership opted to try the self-scheduling protocol in an effort to save time, manage labor costs, maintain positive nurse satisfaction and retention and thereby maintain patient satisfaction. After a successful initial pilot in the ICU, the program was rolled out to all patient care floors and eventually to the other specialty units.

This method has enhanced staff satisfaction, autonomy, professionalism, time control and flexibility. It promotes staff retention and recruitment while reducing manager scheduling time. In some instances, there has been a decrease in unscheduled paid time off because of the staff’s ability to schedule themselves around their home schedules.

“Self-scheduling empowers the nurses to work a schedule that they are able to integrate with the other areas of their life,” said Kristen Parisi, BSN, CCRN, RN, nurse manager of the ICU. “This model provides staff flexibility in balancing both work and home life, while also supporting the delivery of care.”

Pulmonary Rehabilitation registered nurses Ann Carroll, Lisa Finn, and Karen Hamp work with patients who have respiratory diseases or illnesses.

Nurse managers Elaine Schrutt and Linda Butski were among the 2015 bowling teams.

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Surgical technicians and nurses Amy Spendio, Janice Vosburgh and Bonnie Fox enjoyed the 2015 KMH Classic Bowling Tournament.

Nursing Helps Encourage Advance Directive Preparation In an effort to highlight the importance of advance healthcare decision-making, the Palliative Care and Bereavement Committees at Kenmore Mercy Hospital hosted an Advance Directives Day in March of 2015.

Members of the committee provided interested individuals with the required documents, information and tools to assist in making their wishes known to family, friends and healthcare providers.

Formal advance directives are documents written in advance of serious illness that state a patient’s choices for healthcare, or name someone to make those choices when a patient is incapacitated.

“As a result of our Advanced Directives Day, many more people in our community can be expected to have thoughtful conversations about their healthcare decisions and complete reliable advance directive to make their wishes known,” said Kathleen Vitthuhn, MSN, RN, CNML, director of nursing for Medical-Surgical Patient Care Services.

Nursing supervisor Tom Nader, RN, discussed advance directives with an associate.

The goal of the annual event is to help patients, their families, and healthcare providers be better equipped to address advance healthcare planning issues before a crisis and be better able to honor patient wishes when the time comes to do so.

Nurses Educate About Colorectal and Gastrointestinal Diseases In recognition of Colon Cancer Awareness Month in March and Gastrointestinal Nurses and Associates Week, the GI nursing team hosted a Gastrointestinal Education Fair and speakers.

Physicians and nurses from Kenmore Mercy Hospital helped individuals gain a better understanding of colorectal cancer and gastrointestinal diseases, such as diverticular, colitis, and Crohn’s, by offering information on risk factors, prevention strategies, treatment options and nutritional considerations.

Speakers at the events included Timothy Adams, MD, a colorectal surgeon, who addressed colon cancer, and Theresa Jackson, RD, who discussed healthy lifestyles.

Registered nurses Azadeh Hassan-Tehrani and Marie Sullivan spent time talking with a number of visitors.

Registered nurse Cheryl Lewandowski introduced Dr. Adams at the event.

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Adult Nurse Practitioner (ANP) Cheryl W. Hayes, NP

2015 Certifications

Interventional Radiology Nurse Certification Deborah Arnet, RN Kathleen Daley, RN Christine McGee, RN Robert Morello, RN

Certified Emergency Nurse (CEN) Amanda Kramer, RN Heather Telford, RN

Board Certified Nurse Practitioners (CNP) Rita Colicchia, NP Susan DePlate, NP Mary Dowd, NP Susan DePlate, NP Elizabeth Grundtisch, NP Andrea Schmitt, NP Esther Sprehe, NP Sister Mary Walter, NP

Med-Surg Certification (CMSRN) Johanna Boyd, RN Nancy Chojecki, RN Brenda Cramer, RN Annette Gillies, RN Jessica Klug, RN Carole Woomer, RN

Nurse Executive, Advanced-Board Certified (NEA-BC) Cheryl W. Hayes, NP

Certification in Cardiac Medicine (CMC) Sandra Conti, RN

Nurse Executive, Board Certified (NE-BC) Kathleen Vitthuhn, RN Elaine Schrutt, RN

Certified Gastroenterology Nurse (CGRN) Heidi Frushone, RN Janet Gonzalez, RN Jane Weidner, RN

Orthopedic Nursing Certification (ONC) Delreta Billips, RN Alan Chittley, RN Christine Clark, RN Nicole Faulkner, RN Briana Geddis, RN Mary Hojnacki, RN Pamela Koetzle, RN Betty LoFaso, RN Amber Mazurek, RN Deborah Micholas, RN Christine Reaser, RN Susan Wasielewski, RN Suzanne Zeisz, RN

Certification for Nurse Managers and Leaders (CNML) Margy Donofrio, RN Christine Schwinn, RN Ellen Swan, RN Certified Nurse Operating Room (CNOR) Rachel Achtziger, RN Linda Butski, RN Melissa Kowalski, RN Certified Post Anesthesia Nurse (CPAN) Scott Berube, RN Margy Donofrio, RN Pam Farrell, RN Sue Hartl, RN Rene Marriott, RN

Certified Ambulatory Nurse (CAPA) Margy Donofrio, RN Certified Case Manager (CCM) Jodie Cwiklinski, RN Nina DiCarlo, RN Deb Hurd, RN Ella Mendez, RN Sandy Olear, RN

Certification in Wound Ostomy Nursing (CWON) Mary Applegate, RN Certification in Diabetic Education (CDE) Irene Haefner, RN Critical Care Registered Nurse (CCRN) Julie Bajor, RN Scott Berube, RN Melissa Borgese, RN Sandra Conti, RN Christopher Dowd, RN Kristyn Durick, RN Mary LaMartina, RN Lori Ann Meder, RN Tom Nader, RN Kristen Parisi, RN Maria Richardson, RN Bridget Walborn, RN Elizabeth Wood, RN Lisa Smith, RN

This list includes certifications completed prior to December 2015.

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Foundation Funding Provides Education to Nursing Staff A special thank you to the Kenmore Mercy Foundation who raises funds to provide key financial support for staff education. In 2015, the Foundation funded more than $17,000 in courses for nursing associates, including those listed below.

2015 ANCC Magnet Conference Cardiac Symposium (4) CEUs for certification (CTSGNA) Society for Gastroenterology Nurses and Associates CEUs for certification (CTSGNA) CEUs for certification (RRHS) Critical Care Conference (3) Critical Care Nursing Certification: Review books (5) Continuous Service Readiness Joint Commission Conference Dementia Education (2) Dynamic Stretching Course Emergency Nurses Association Emergency Nurses Association Conference-Faculty Presentation (2) Essentials of Nurse Manager Orientation Greater Rochester Finger Lakes Central Service Association (10) International Association of Healthcare Central Service Material Management 2015 Fall Education Seminar Improving Wound Care 2015 Fred Pryor Leadership Seminar (2) Musculoskeletal Symposium (6) National Teaching Institute (Critical Care) (2) Neurology Update for Primary Care Professionals (11) Neuromuscular & Neurodegenrative Disorders North American Spine Society National Meeting NRC Picker Patient Satisfaction Conference Nurse Manager Survival Skills (2) Nursing Conference on Critical Care Nursing Research Conference-Poster presentation (8) Operating Room Manager Conference Orthopedic Educational Seminar (2) Palliative Care Seminar (8) Preventing Post-Operative Complications (3) Radiological Society of North America Annual Meeting Rochester General Hospital GI Teaching Day (2) SGNA Annual Course to Maintain GI certification Understanding Depression & BiPolar Disorder (2) WNY Society for Gastroenterology Nurses and Associates Fall Conference Wound Care Conference

Much of the funds raised by the Foundation come from their Tribute to Angels Event held in November. Surgical staff Donna Hall-Anderson, Jennifer McCarthy, Ellen Colan, and Andrea Schmitt attended.

Nurses Jessica Klug and Amber Mazurek enjoyed attending the Tribute to Angels Event.

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Move with Care Making Associates and Patients Safer After months of training and rolling out new equipment, Kenmore Mercy Hospital officially kicked off its Move with Care safety program in July 2015.

Number of Lost Work Days Due to a Patient Handling Injury, January 2015-January 2016

The new safety program increased patients’ quality of life, reduced falls, skin ulcers and shearing, and helped prevent nursing injuries that occur when lifting or repositioning patients.

“The average caregiver lifts or moves nearly 3,000 pounds in an eight to twelve hour shift,” said Ellen Swan, BSN, RN, CNML, nurse manager on the 2 West Patient Care Unit and the Move with Care nursing champion.

According to the United States Department of Labor, more workers are injured in the healthcare and social assistance Lost days after intervention are related to associate injury industry sector than any other. In 2010, the healthcare and prior to implementation on July 28, 2015. social assistance industry reported more than 653,900 cases of injury and illness. That is 152,000 more cases than the next industry sector - manufacturing.

By partnering with Diligent® Guaranteed Solutions to provide new, easy to use equipment and training to staff, the hospital hopes to alleviate many of those issues while also providing a safer environment for patients.

Equipment to assist in the lifting and moving of patients has been placed on every unit. Master Movers, staff members extensively trained on the proper use of the equipment.

Registered nurse Kayla Limbardi and nursing student Amy Coniglio, demonstrate the Sara Steady.

Registered nurses Daren Powers and Christine Logan demonstrate the Sara Plus.

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New Knowledge, Innovations & Improvements Bed Ahead Optimizes Emergency Department Throughput In response to concerns about patient admission delays in the Emergency Department, staff at Kenmore Mercy developed the “Bed Ahead” process. Under the system, inpatient units anticipate demand, by measuring demand over time, and have a bed ready into which a patient can be moved as soon as the demand occurs.

However, developing this new system took time and the efforts of several disciplines. The process to admit a patient branches throughout the hospital, touching numerous departments, including nurses, unit clerks, environmental services staff, nursing supervisors, patient access associates, quality and patient safety associates, and ED physicians and hospitalists.

In reviewing the old process, it was noted that the interprofessional communication at the time was not effectively meeting the demands of the volume of patient admissions from the ED. Eliminating delays in sending a patient from the ED to the next level of care required that each department or area coordinate with one another and see itself as part of the same overall system. Because waits, delays, and cancellations are so common in healthcare, patients and providers assume that waiting is simply part of the care process.

A time study, measuring the time of admission order to the time the patient physically left the ED, was performed and a significant decrease in time was noted after the “Bed Ahead” intervention began in October 2014.

Unfortunately in the months of December 2014 and January 2015 the Western New York area experienced two separate snow storms. This left the area in a crisis state. Patients were unable to be discharged to home due to being unable to safely transport them during the snow storms. This led to a temporary inability to admit patients to the inpatient setting due to a lack of available beds. However, in February 2015, the initial process improvement gains seen by the team were retained once the “Bed Ahead” concept was back in place.

Based on a recent Intensive Care Unit survey, 69% of nurses expressed that the “Bed Ahead” process is an effective way to communicate the availability of beds, therefore preventing a delay in ED patient transfers.

In addition, it has been reported that the new process allows time for the inpatient clinical nurse to review the patient information in the ED’s electronic documentation system as soon as they are aware of a potential admission. This allows for the ability to proactively plan the patient assignment based on the nurses’ competency.

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Hero at Zero - How Nursing is Championing Pressure Ulcers Pressure ulcers have been a major curse of hospital caregivers for as long as hospitals have existed. Therefore, Kenmore Mercy’s recent record, of zero hospital acquired pressure ulcers, recorded on Skin Prevalence Day, from October to December 2015, is reason to celebrate! The hospital saw a 200 percent reduction in pressure ulcers since January 2015.

Kenmore Mercy’s nursing team addressed the ageless problem of pressure ulcers, also known as bed sores through standardization of pressure ulcer specific interventions, working with multidisciplinary teams and leadership, addressing accountability and celebrating success, designating skin champions and providing education.

Kenmore Pressure Ulcers KMH Mercy Pressure Ulcers

250%

2.16

200% 150% 100% 50%

0.75

0.00

0.00

1.04

0.99

0.85

0.78

0.00

0.00

0.00

0.00

0%

Hospital Acquired Pressure Ulcers

2015 Target = 1.29

According to Cheryl Hayes, MS, ANP, NEA-BC, vice president of Patient Care Services, “We were able to present a significant amount of education in 2015, which benefited our associates and their patients.”

Mary Applegate, CWON, RN, wound ostomy nurse and skin care educator, expanded, noting that skin care education was increased from one hour to four hours for all newly hired nurses and nursing attendants. In addition, an all-day pressure ulcer continuing education session was offered for all current staff. Nursing also designated skin champions who helped further educate staff on a monthly basis.

In addition, 2015 ushered in the Move with Care program. While the program’s key goal was safe moving of patients and reduction of associate injuries, a bonus was helping to reduce the risk of shearing and friction. Incontinence associated dermatitis protocols were also put into place to reduce the risk of pressure ulcers.

Over the past year, patients also benefited from new Isoflex Air mattresses on all beds, which provides pressure redistribution and shear management through a memory gel material.

Mary added, “Great teamwork across all of the hospital was a significant contributing factor.” The Intensive Care Unit contributes through their ABCDE bundle protocols; while the Operating Room has new beds and gel pads for positioning.

Pressure ulcers can become painful, infected, reduce health related quality of life, and increase length of hospital stay.

Congratulations to Kenmore Mercy’s nurses. By working together, you put our patient safety first, prevention and healing pressure ulcers.

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Empirical Outcomes Kenmore Mercy Exceeding Patients’ Expectations The challenges of providing patients with a positive healthcare experience are undisputable. Recent patient surveys show that Kenmore Mercy Hospital’s dedication to meeting these high demands, while providing high quality care, is making a difference.

In 2015, 72.6 percent of inpatients surveyed rated their experience a nine or a ten. While not significantly different than the ratings in 2014, it is still reason to continue paying attention to survey comments.

KMH Patient Experience Overall Rating 100%

As of 1.7.16. Partial Data for Oct 2015.

90% 80% 70%

72.6%

73.7%

YTD Oct 2015

2014

60%

69.0%

50%

According to Laura Verbanic, PT, BB, CPHQ, director of Quality & Patient Safety, “The most common patient complaints are typically wait time, responsiveness to call lights, room cleanliness, manner of staff, and poor communication.”

Overall Rating Positive Response

2013 2015 Target = 75.95%

A few of the tactics used in the past year to improve patients’ perceptions of the hospital include: implementation of “Picture Perfect” rooms, use of luminometers to ensure patient rooms are clean, purposeful rounding by nursing, creation of a Patient & Family Advisory Council, the purchase of new furniture for both the patient floors and lobby, the Pet Therapy Program, and nursing units working on nursing specific indicators.

Thank you to all of our nursing associates for their work to achieve these impressive results!

Tank, pictured above with his owner/handler Eileen Gramlich, RN, visits with patients.

Nurses attendants Amy Whalen and Delores Watkins prepare a “Picture Perfect Room.”

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Hospital Making Strides to Reduce C. Diff Control of Clostridium difficile infection (C. Diff) outbreaks in hospitals presents significant challenges to healthcare workers.

Kenmore Mercy Hospital has made major strides in the past year to reduce infections.

KMH C-Diff C-Diff Rates 12 10

The hospital experienced a significant reduction in C. Diff infections in 2014 and was able to sustain that rate in 2015, thanks to continued interprofessional collaboration.

This included cleaning high touch surfaces/non-critical equipment using bleach wipes, which are effective in destroying the C. Diff spore; using of a NovaLum™ Luminometer, which measures how well a surface was cleaned; improved hand hygiene; and placed patients in isolation at onset of symptoms. In addition, nursing and environmental services staff was re-educated about the Picture Perfect Room initiative.

10.37

8 6

6.30

5.90

YTD Oct 2015

2014

4 2 0

C-DIFF Rate per 10,000

2013 2015 Target = 5.31

According to the Centers for Disease Control and Prevention, 94 percent of C. Diff infections are related to receiving medical care. Hospital stays from this infection tripled in the last decade, posing a patient safety threat especially harmful to older Americans. The infection causes diarrhea linked to 14,000 American deaths each year.

Nursing Working to Reduce CLABSI Risks

CLABSI Rates KMH CLABSI

Sustained reduction of central line-associated bloodstream infections (CLABSIs) remains elusive in many institutions.

4

According to Jennifer Carlson, Infection Control specialist, “We’ve taken action to train staff and better maintain central lines to avoid these infections.”

Nursing identifies patients flagged with central lines daily in Soarian. This allows providers to better address the need for the line.

There were focused efforts on device utilization (number of central lines/patients days) reduction. If less central lines are present in patients, there is a lower chance of infection.

2.87

3

2.35

3 2 2 1 1

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 CLABSI RATE per 1,000

Jul-15 Aug-15 Sep-15 Oct-15 2015 Target = 0.60

The hospital has sustained efforts from 2014 and maintained the same number of CLABSIs. Of special note, the Intensive Care Unit has remained CLABSI free for three years.

CLABSIs are avoidable through proper insertion techniques and management of the central line, but they continue to be a common hospital-acquired infection in the United States: an estimated 41,000 CLABSIs occur each year in the U.S., according to the Centers for Disease Control and Prevention.

Unit clerks Helen Rovillo, Tina Attea, and Katherine McCann, meet with other members of their team monthly.

Registered nurses Christine McGee and Kathy Daley help patients during interventional radiology procedures.

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Registered nurses Samantha Belter, Jessica Yormick, and Julie MacDonald helped raise Helping Hands Funds on Ugly Christmas Sweater Day.

OUR MISSION

We are called to reveal the healing love of Jesus to those in need.

OUR VISION

Inspired by faith and committed to excellence, we will lead the transformation of health care in our communities.

OUR VALUES

Reverence Nursing reflects our values and mission by the acknowledgement of the sacredness of human life and the individuality of their needs and goals.

Compassion Nursing provides compassionate care by identifying the connectiveness of each person through the relationship with each other and their environment.

Justice Nursing advocates for our patients to achieve their personal goals, respecting and recognizing the differences in each individual.

Excellence Nursing continually strives for quality and excellence through the care we deliver through communication to our patients, families and the interdisciplinary team.

Nursing strives to interact with our patients to achieve their goals, promote, maintain and sustain health and to ensure satisfaction of the care the patient receives.