Rex Healthcare Nursing Annual Report 2012-2013

The strength of the team is each individual member. The strength of each member is the team. - Phil Jackson

From the Chief Nursing Officer Dear Rex Friends and Colleagues, The theme of the 2013 Nursing Annual Report is TEAMWORK. Rex Nurses are unified in powerful TEAMWORK that improves the quality of nursing care and patient outcomes, enhances the patient experience, increases efficiency in care delivery, and serves as a catalyst for professional and organizational growth. In this annual report you will see once again that 2013 was another year of Rex Nurses joining together to live our mission: “To make a positive difference in the lives of our patients every day.” During 2012 and 2013, our nurses strengthened great teamwork (which began in 2011) with our patients and families to form the first Family Advisory Council at Rex Healthcare. This partnership among nurses and patient families supports excellence in family centered care. In this expanding model, nurses will work more closely with family members to improve the quality of care we provide and the overall experience of our patients. In the closing days of 2012, the UNC Health Care System selected a partner for our system electronic health record system. Throughout that year, several of our Rex Nurses were part of a core team of approximately 120 individuals from across the UNC Health Care System who trained to assist with the implementation of Epic@UNC at UNC Hospitals, Rex Healthcare, Chatham Hospital, the UNC Physicians Network and UNC Physicians & Associates. Largely behind the scenes, this team did the heavy lifting to prepare for our go-live in June of 2014. It was a hallmark moment for our health system as we began to share a common electronic health record creating one patient ID, one problem list, one medication list, and one bill for each patient. I am so very proud of our nurses who served as part of that team. When I look at the faces of the nurses on this annual report and across Rex Healthcare, I see nurses who are compassionate, capable, confident, and centered on the patient and their families. I see a team of nurses continuing Rex’s 120 year legacy of serving the Raleigh community with nursing excellence. Although I joined the Rex team after the work in this annual report was accomplished, I am reminded daily of the strength, compassion and skill of Rex Nurses. It is my honor to serve alongside such special caregivers.

Joel Ray, R.N., B.S.N., M.S.N. Vice President Patient Care Services/Chief Nursing Officer

OUR MISSION To make a positive difference in the lives of our patients every day.

Joel Ray

Collaboration is the best way to work. It’s the only way to work, really. Everyone’s there because they have a set of skills to offer across the board. - Antony Starr

“Hospital to Home” Initiative Reduces Cardiac Patient Readmissions In October 2012, new regulations by the Centers for Medicare and Medicaid (CMS) began impacting hospital reimbursement for patients readmitted within 30 days of discharge by denying payment to the hospital for the readmission. Preventing readmissions for Heart Failure patients became a priority at Rex Healthcare. In preparation for this, Joánne Kuszaj, M.S.N., R.N., Director of Cardiovascular and Pulmonary Nursing, advocated for the establishment of a Rex Hospital to Home (H2H) committee. H2H is a joint project developed by the Institute for Healthcare Improvement and the American College of Cardiology to reduce readmissions and improve transitions of care for cardiovascular patients. Mary Lou Powell, R.N., M.S.N., Chief Nursing Officer, and Dr. Linda Butler, Chief Medical Officer, supported Kuszaj’s suggestion to develop this inter-professional committee. When the H2H committee was established, the Rex heart failure readmission rate was 9 percent. The committee began by focusing on the reason for the readmissions for heart failure patients. It was determined that not all Rex patients had a primary care provider (PCP) prior to admission to the hospital. This made it difficult to set up an appointment with a new provider that could occur within 7-10 days after discharge from the hospital. A business plan was developed to open the clinic run by MaryClare Prasnikar, R.N., M.S.N., C.C.R.N., Clinical Nurse Specialist for Cardiovascular Services, with the assistance of a pharmacist and a nutritionist. The clinic was opened on October 16, 2012. Patients are referred to Prasnikar by providers as well as clinical nurses. Each appointment lasts approximately an hour with Prasnikar checking the physical status of the patient and reviewing the heart failure education to help assure patient understanding of self-management. A pharmacist reviews all medications and educates patients on the reasons for their medications and the side effects, and a nutritionist discusses the heart healthy diet.

Joánne Kuszaj, R.N., M.S.N., and MaryClare Prasnikar, R.N., M.S.N.

Heart Failure Readmission Rate

9% 6.95%

2012

2013

5.86%

2014

Since the readmission clinic has opened, no patients who were seen in the clinic have been readmitted to the hospital within 30 days of discharge. The overall heart failure readmission rate decreased to 6.95% in FY2013 and 5.86 for FY2014 (July 2013 - May 2014).

Unity is strength…when there is teamwork and collaboration, wonderful things can b

Medication Cards Improve Patient Education In an effort to improve patient education regarding medications, a hospital-wide initiative was put in place titled “MEDS - Always Ask.” MEDS stands for Medication, Explanation, Dosage, Side Effects. Using this strategy, the nurse explains each new medication, its dosage and side effects. The patient is also given a comprehensive, computer-generated information sheet – much like the information flyer received at the pharmacy when purchasing medications – which could be overwhelming for patients.

Acetaminophe

n (Rex Hospital Formu lar y) Brand names: Ace Lawson Item# phen™ [OTC]; Fev 338996 erall® [OTC]; Tyleno ® Extra Strength [OT ® Update: 7/14 l [OTC]; Tyleno ® C] l What is it us

ed for? To eas e pain and fever Possible Side Effects? • Signs of an allergic reaction • Signs of live r problems like dar k urine, feeling tire stomach pain, ligh d, not hungry, up t-colored stools, set stomach or • Unable to pas throwing up, or yellow skin or eye s urine or chang e in the amount s • Change in thi of urine passed nking clearly and with logic • A ver y bad skin reaction

Morphine

Lawson Item# 339122 Update: 7/14

Brand names: Astramorph/PF™; AVINza®; Duramorph; Kadian®; MS Contin® What is it used for? Moderate to severe pain Possible Side Effects? • May cause itching, hypotension, dizziness, drowsiness, impaired coordination, or blurred vision; loss of appetite, dry mouth, nausea, or vomiting; or constipation (if unresolved, consult prescriber about use of stool softeners). • Report chest pain, slow or rapid heartbeat, dizziness, or persistent headache; Dip confusion or respiratory difficulties; or severe constipation.

henhydramine

Brand names: Benadryl; Som

Also found in many more over-t

inex; Allergy Relief [OTC]

Lawson Item# 339007 Update: 7/14

he-counter brand name produ

Recognizing that our education and follow-up information needed to be more concise, easy to explain and in a readable format, medication side effect cards were designed. A collaborative team, consisting of nurses, pharmacists and marketing colleagues, worked together to design and trial the cards. Utilizing the medication side effects cards, nurses educate their patients on new medications given during their hospital stay. The nurse also reinforces the understanding of medications the patient will be taking at home. The medication side effects card includes the name of the medication, common uses and common side effects. After discussing the medication, the nurse places the medication information in the patient’s personal education folder, which the patient takes home at discharge. The medication side effects cards were trialed on two units in the hospital. Data from the initial trial indicated an improvement in patient medication teaching and understanding of medication side effects. The medication side effects cards were then implemented on all inpatient units at the hospital. Each nursing unit compiled a list of the top 20 medications used on their units. A library of medication side effects cards was developed. The medication cards are reviewed by pharmacy on a routine basis for new medication updates and accuracy of content.

be achieved. - Mattie Stepanek

cts

What is it used for? To ease allergy symptoms, runny nose, motion sickness, hives, itching, swe lling or sleep problems Possible Side Effects? • Sleepiness, dizziness • Dry mouth, thickening of mucus in the nose or thro at • Feelings of nervousness and excitability, poor coordina tion • Blurred vision, illogical thinking • Constipation, stomach upset • Report immediately to your doctor if you are not able to pass urine, or experience severe weaknes s, rash, or hallucinations • Should be used with caut ion in men with prostate prob lems

Wanda Adams, R.N., B.S.N.; Tonya Faulkner, R.N., B.S.N., P.C.C.N.; and Janice Laurore, R.N., B.S.N.

Teaming Up to Exceed Patient Expectations

By the summer of 2013, each team met individually to develop their specific strategy to increase patient satisfaction. Each team presented their

7West Patient Satisfaction Percentile Ranking for Overall Quality of Care

2013

87%

Using an innovative team approach, all co-workers on 7West were asked by the nurse manager to participate on one of eight teams. The teams include registered nurses, nursing assistants and unit secretaries. The eight teams identified were: • Staff friendliness and courtesy • Overall level of safety • Communication with nurses • Responsiveness of staff • Pain management • Communication with nurses • Communication about medications/armband check • Hospital environment including cleanliness and quiet • Discharge information

action plan during staff meetings and in daily shift change huddles. Throughout the year, the nurse manager shared monthly scores with each team facilitator and all co-workers during monthly staff meetings. As a result, the 7West patient satisfaction excellent percentile rank for “overall quality of care” averaged in the 87th percentile, representing a 48% increase over the year. The 7West team ultimately recognized that when patient expectations are met the patients are more satisfied and have better outcomes.

75%

A major component of quality health care is patient satisfaction. Listening to patients’ feedback is the most important way to learn about their experiences with Rex staff and services. Patient satisfaction at Rex is measured through a survey conducted by Professional Research Consultants, Inc. (PRC) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). In 2013 co-workers on 7West, the general surgery unit, developed a strategic plan for exceeding the 75th excellent percentile rank for patient satisfaction in overall quality of care.

2014

Keep the Beat … Move Your Feet The “Keep the Beat, Move Your Feet” project focuses on early mobility in patients who undergo open heart surgery. Education begins in the surgeon’s office where patients are provided with a copy of The Cardiac Surgery Patient Pathway. The pathway defines what patients should expect during their stay, beginning with the pre-operative visit and continuing through discharge. Emphasis is placed on the importance of early mobility and patients are educated on the expectation that they will be getting out of bed to the chair and beginning to walk on postoperative day one. Twelve months of data collected after the project began showed that mobilizing patients earlier in their stay decreased the number of days patients were hospitalized after surgery. The results also showed a decrease in post-operative complications of pneumonia, blood clots in the legs and readmissions at 30 days. Additionally, the quality of patient sleep was reviewed. Patients are now provided with eye masks and ear plugs, at their request, to promote sleep, in addition to quiet hours being implemented on the nursing units. “Keep the Beat, Move Your Feet” has increased patient and family involvement in care, decreased complications and has shown a positive financial impact.

Heather Dionne, R.N.; Betsy Whitmore, R.N., B.S.N., M.S., G.N.C.; Sandy Waugaman, R.N., B.S.N., C.C.R.N.; and Charlotte Van Northwick, R.N., C.C.R.N. (Not pictured: LeeAnn Bradley, R.N., B.S.N.)

Readmissions

14%

12% 8%

Pre-Mobility Program

Mobility Program Months 1-6

Mobility Program Months 7-12

Great things in business are never done by one person. They’re done by a team of people. - Steve Jobs

Decreasing Time from First Medical Contact to Cardiac Cath Lab Intervention Average Time from First Medical Contact to Intervention

Q2 2012

91 Minutes

Q3 2014

65 Minutes A decrease of

28.5%

Rex Healthcare’s Heart Attack/ST Elevated Myocardial Infarction (STEMI) program has been in place since 2007. As a Primary Percutaneous Coronary Intervention (PCI) Center, Rex participates in the AHA Mission: Lifeline and the RACE initiative (Reperfusion of Acute Myocardial Infarctions in Carolina’s Emergency departments). Through this initiative, the interdisciplinary team implemented strategies to decrease the time from when a heart attack patient arrives to when the blocked artery in their heart is open. During the May 2012 STEMI Committee meeting, it was realized that patients were getting their blocked arteries open 50 percent faster than they had at the beginning of the program. A new goal was established: First-MedicalContact-to-Intervention (FMC2I) in less than 90 minutes. This measures the time from when the patient makes contact with EMS or walks into our Emergency Department to the time the blocked artery is open. In subsequent meetings the committee began to further investigate the current practice for STEMI patients by breaking down the process into three elements: time with Emergency Medical Services (EMS), time in the Emergency Department (ED) and time in the Cardiac Catheterization Lab (Cath Lab). Two variables, EMS transport time and time in the Cardiac Cath Lab, could not be appreciably altered. Therefore the committee concentrated on the process for the STEMI patient while in the ED. In June 2012, information was presented to the ED leadership regarding the variability of time of patients in the ED. The ED staff identified elements that were potentially creating delays of movement to the Cath Lab, such as procedures and time of day. This data was used to streamline the process so that qualifying patients would pass through the ED and proceed directly to the Cardiac Cath Lab. In January 2013 the “passthrough” process was brought to, and later approved by, the STEMI Committee.

This process created a more efficient use of nursing resources by improving throughput to the Cath Lab. This, in turn, has helped to improve the outcome of the STEMI patient, since the patient will be passing through the ED, enabling quicker intervention to the blocked artery. In addition, it enhanced the nurse-to-nurse handoff with face-toface report by the STEMI team’s ED or CICU nurse who accompanied the patient. Finally, since the STEMI team accompanies EMS to the lab, the team lends additional, temporary nursing resources to the Cath Lab team, assisting with the care of the patient and expediting patient readiness for PCI.

Sherry Whitt, R.N., B.S.N., M.S.H.A.; Sara Liles, R.N., B.S.N.; Elaine Marshall, R.N., B.S.N., M.H.A.; Charles Cheek, R.N., B.S.N., C.C.R.N., C.N.M.L.; Sonya Mangum, R.N., B.S.N.; and Shae Earles, R.N., B.S.N., EMT-P

Through this work, the time from First-Medical-Contact-to-Intervention has decreased from an average of 91 minutes in Quarter 2 of 2012 to 65 minutes for Quarter 3 of 2014. Of note, in April 2014, Rex Healthcare received the 2013 Mission Lifeline Silver award for meeting all nine performance measures for 12 consecutive months.

Alone we can do so little; together we can do so much. - Helen Keller

Smoothing the Transition to Rex for Cardiology Patients In 2012, a large cardiology practice in the region decided to shift their patients to Rex. Realizing this practice routinely transferred in more than 75 patients each month from outlying hospitals, Rex leaders knew this would mean a dramatic increase in the number of transfers into Rex. Former Chief Nursing Officer Mary Lou Powell, R.N., M.S.N., immediately understood accommodating this rapid growth would be an organization-wide challenge. Successfully managing this influx of patients would require engaging other sub-specialists (not only the cardiologists) in accepting an increased number of consultations, many of which occur after-hours when Rex physicians traditionally provided “on-call coverage” only for patients seen in the Emergency Department. It would also require developing an efficient means to safely transport these patients to Rex Healthcare. Many of these patients would require critical care services to transfer them from the outlying hospitals. Identifying evidence-based practices, Powell, Chief Medical Officer Dr. Linda Butler and Sherry Whitt, Director of Emergency Services, reviewed published literature on medical transport services and transfer centers, evaluated the services of a variety of vendors, and visited healthcare systems with regional transfer centers. A multidisciplinary team was formed, comprised of representatives from nursing, the hospitalist team, critical care transport, information technology, case management and diagnostic services. The team had a 3-month timeline to implement a Transfer Center at Rex. In July and August employees were trained on the new process and the use of new tracking software, critical care dispatchers were relocated to the main campus within the administrative coordinators office, and experienced nurses were added to the team to serve as Transfer Center nurses.

The critical care transport service, administrative coordinators, critical care dispatchers, bed placement reservationists, and the Transfer Center nurses were brought together under the direction of Sherry Whitt, Director of the Emergency Department, and officially went online in October 2012. Dr. Butler, the Physician Network Specialist and Sherry Whitt went to each referral hospital to partner with each hospital’s leadership and orient them on the process of transferring patients to Rex. Our Results Since the successful implementation of the Rex Transfer Center, significant improvements in efficiency and patient care have been realized: • Ninety percent of the time a decision for acceptance of a transfer is made within ten minutes of the request. • The positive reputation of this program has resulted in greater use by all services. Cardiology services accept more than half of the transferred patients. The remainder are requested and accepted by a variety of medical and surgical services. • As part of the evolution of the service, the transport staff can transmit a real-time electrocardiogram to the attending physician at Rex. Additionally, real-time communication with the Rex Intensivists has been implemented for our patients inbound to the intensive care areas. • Patients require either advanced life support transport or critical care transport services. Because of an increased demand for air transport, a state-of-the-art helipad has been built on top of the Rex Emergency Department and was fully operational in May 2014.

To me, teamwork is the beauty of the sport, where you have five acting as one. You b

Sherry Whitt, Director Emergency Services/Transfer Center/CCT/Patient Reservations; Dr. Linda Butler, Vice President of Medical Affairs/Chief Medical Officer/Chief Medical Information Officer; Sharon Stocks, R.N., Transfer Center;Jeanne Tomlinson, EMT; and Alan Foster, Manager, Community Emergency Management/Critical Care Transport

Number of Patient Transfers Received by Rex Healthcare 160 140 Intervention: July - Sept. 2102

120 100 80 60 40 20 0 6/12 40

7/12 40

8/12 55

become selfless. - Mike Krzyzewski

9/12 64

10/12 61

11/12 118

12/12 120

1/13 143

2/13 116

3/13 141

Cardiovascular Nurse Practitioner Program Fosters Growth In today’s healthcare system, organizations are faced with significant challenges and cost as they care for a patient population that is advancing in age and experiencing more complex health issues. Cardiovascular disease is the leading cause of death for both men and women, accounting for more than 800,000 deaths each year and costing the healthcare system more than 108.9 billion dollars annually (CDC, 2014). One of the goals of Rex Healthcare was to enhance and expand cardiovascular services and become a regional referral center for Rex and the UNC Healthcare System. To achieve this, Rex’s strategic plan included two essential items. First, the Rex Healthcare Board of Trustees approved the construction of a 150-bed cardiovascular center of excellence. Second, the cardiovascular physician group was expanded and now employs 31 cardiologists. This physician group provides comprehensive cardiovascular care for a 16-county area that covers 100 miles from east to west and 70 miles north to south. Due to the vastness of the service area, increasing inpatient volumes and the expansion of the cardiovascular service line, Rex Healthcare administration and physician leaders of North Carolina Heart & Vascular (NCHV) identified the need to establish an Inpatient Cardiovascular Nurse Practitioner (N.P.) Program. This new program would facilitate the expansion of the cardiovascular service line for the organization and the UNC Healthcare system, and two goals were identified. The implementation of an Inpatient Cardiovascular Nurse Practitioner program will ensure that care provided by NCHV will facilitate the expansion of: • The number of cardiovascular procedures performed in the Rex cardiac cath lab • The number of cardiology admissions to Rex Healthcare The Heart and Vascular Administration N.P./P.A. Program was established in January 2012 when Margaretann House, D.N.P., R.N., F.N.P.-B.C., was hired as the Director of the Inpatient Cardiovascular Nurse Practitioner Program. From January to September 2012, House developed the program with clearly established goals and objectives, a comprehensive orientation plan, continuing educational programs, and integration of the APRN on many organizational teams and committees. Education and team building about the roles and responsibilities of the cardiovascular NPs was provided to all Rex Healthcare coworkers (nurses, physicians, case managers, discharge planners, pharmacists,

A Valuable Team Member The Advanced Practice Registered Nurse (A.P.R.N.) role of the N.P. has continued to evolve and expand in order to fill gaps in access to quality care for millions of Americans in a variety of healthcare settings. The N.P. provides services in a variety of patient care areas to include primary, specialty, acute and critical care environments (American Academy of Nurse Practitioners [AANP], n.d.). The scope of practice of the N.P. includes performing well visits, history and physicals, ordering and interpreting a variety of diagnostic studies, performing hospital rounds, prescribing medications, assisting in surgical procedures, patient education and counseling, making referrals, developing treatment plans, coordination of care, and monitoring the effectiveness of therapeutic interventions.

Marianne Burger, N.P.; Ross Goldblum, P.A.; Margaret Ann House, D.N.P., F.N.P.-B.C.; Chad Royster, N.P.; Paula Jones, N.P.; Kyle Pusey, P.A.; Christine Laramee, N.P.; Chelsey Dyches, P.A.; and Amanda Wilson, P.A.

occupational therapists, respiratory therapists, administration and other support staff members), as well as patient and families. In September 2012 the first co-worker was hired and staff has been incrementally added to achieve the current level of staffing and will continue to increase proportionately to the increasing patient volumes. The program supports NCHV. Since the inception of the program, cardiology admissions have expanded from 1,849 in the 4th quarter of 2011 to 2,615 in the 1st quarter of 2014, and electrophysiology (EP) and cardiac catheterization procedures has increased from 1,745 in the 4th quarter of 2011 to 3,227 in the 2nd quarter of 2014. Additionally, the development and implementation of a structured Inpatient Cardiovascular Nurse Practitioner (N.P.) Program within the organization to support the cardiologists of NCHV has enabled Rex Healthcare to

provide comprehensive, cost effective, coordinated care in accordance with evidenced-based practice and quality care indicators that will ensure optimal reimbursement, reduced costs, quality care based on guidelines, safety, and patient and staff satisfaction.

American Academy of Nurse Practitioners (n.d.). All about NPs. Retrieved from http://www.aanp.org/all-about-nps Centers for Disease Control and Prevention (2014). Retrieved from: www.cdc. gov/heartdisease/facts.htm Institute of Medicine (2010). The future of nursing: Leading change, advancing health. Retrieved from http://www.iom.edu/reports/2010/The-Future-of-Nursing Mezey, M., McGivern, D., Sullivan-Marx, E., & Greenberg, S. A. (2003). Nurse Practitioners: Evolution of advanced practice (4th ed.). New York, N.Y.: Springer. Rex Healthcare. (n.d.). www.rexhealth.com. Robert Wood Johnson Foundation (2011). Health Reform GPS: Navigating the Implementation Process []. Retrieved from: http://www.healthreformgps.org/ summary-of-the-legislation.

Using Pain Assessment Tools for Patients Who Cannot Self Report Patients who have had surgery are asked to rate their pain by reporting a number between 0 and 10 with 0 being no pain and 10 being the worst pain ever. Describing pain as a “number� can be hard for some patients right after surgery. Nurses in the recovery room were concerned that pain in these patients might be overlooked and possibly undertreated. Pain assessment tools in which nurses observe and score pain behavior may be used when patients cannot self-report. While nurses in the recovery room were accustomed to watching for changes in heart rate and blood pressure and changes in patient behavior, they did not use behavioral pain assessment tools to assess pain. To be accepted in practice, the pain scores obtained from nurses must be the same as pain ratings reported by patients. To be useful in practice, the tools have to be easy for nurses to use. To this end, the research study compared the pain ratings from three behavioral pain assessment tools to the patient’s self-report of pain. Nurses on the research team then rated the three scales for ease of use.

Tamara Barnett, R.N., B.S.N., M.H.A.; Pam Beacham, M.S.N., R.N.C., C.N.S.; Tonya Gryniv-Chavis, R.N.; Ramonita Rodriguez-Begley, R.N.; and Janet Stevens, R.N.

Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the

The study found that observational pain assessment was feasible in the recovery room. These tools are now available to be used for any patient who cannot selfreport pain.

fuel that allows common people to attain uncommon results. - Andrew Carnegie

Pathway for Advancement in Clinical Excellence (PACE)

PACE is the evidence-based clinical ladder program at Rex Healthcare. The clinical ladder was developed to provide eligible nurses opportunities for professional growth, personal satisfaction, recognition by the organization as well as by peers, and economic reward, and encourage experienced nurses to remain in bedside positions that provide direct patient care. The main goal for the program is to provide high quality, cost effective patient care through utilization of expert, qualified nursing personnel. Organizations with nursing clinical ladders have better patient outcomes, decreased length of stay, higher staff satisfaction and fewer complications of treatment. Nurses at Rex are eligible to participate in the clinical ladder after two years of clinical experience at the bedside. Nurses have the opportunity to meet the requirements of the ladder in a variety of ways, including continuing education in nursing, unit-based projects, hospital committees, volunteering in the community using nursing skills, and nursing leadership roles including charge nurse and preceptor for nursing students and new employees. The clinical ladder has been in place at Rex for twelve years and has seen almost

Nursing Congress

yearly increases in the number of participants. For fiscal year 2012, there were a total of 270 nurses at Rex participating in the clinical ladder, and in 2013 there were 259. Participants are celebrated with an annual brunch, a decorative pin and certificate, and supplement to the hourly wage for work hours spent providing direct patient care. Participation in the PACE program is completely voluntary and facilitated by managers, educators, and selected PACE mentors who assist the applicant in assembling a professional portfolio that highlights the applicant’s activities for the previous year. Portfolios are reviewed and approved annually by the PACE committee, which is composed of staff nurses from all areas of the organization. The PACE program was developed and is managed by staff nurses with support from hospital leadership.

Nurses and Parents Team Up to Form Family Advisory Council for SCN The Rex Special Care Nursery (SCN) is a Level III, 15-bed unit that serves premature and sick infants. More than 500 babies are cared for annually by board certified Neonatologists, specially-trained neonatal nurses, respiratory therapists and a highly skilled multidisciplinary team. In 2012, nurses collaborated with several former SCN parents in the formation of a Family Advisory Council. One of the earliest goals of the council was to improve parent confidence and communication with nurses. Nurse mentors to the council asked parents to identify ways that nurses could improve communication with parents. Parents shared frustration at not knowing how long their baby would be in the hospital and not feeling prepared for the eventual day of discharge. Nurse mentors and the parents identified specific “milestones” that both the baby and the parents needed to achieve prior to the day of discharge. A learning tool was designed by the council titled “Ready, Set, Go! Family and Baby Milestones.” The tool is now in use by families and serves as a guide to help parents feel empowered and prepared for the day of discharge. Through collaborative efforts of the council, two videos were also created to help empower parents as partners in care. The videos focus on the journey of both the mother and the father during the SCN experience. On the videos, former SCN parents shared wisdom, tips and comfort to reach out and support new SCN parents. Both initiatives are a testimony to the power of collaboration between nurses and parents. Through further collaboration with the Family Advisory Council, nurses and parent advisors worked to improve parent awareness of the importance of skin-to-skin time between parent and baby, also known as “Kangaroo Care.” Kangaroo care offers great benefit to the healing and wellness of both baby and parent. The Special Care Nursery received a grant from the Rex Foundation to

Caron Hodges, SCN Parent Advisory Council; Michele Clements, R.N., B.S.N.; and Karen Hogan, SCN Parent Advisory Council

purchase specialized kangaroo care wraps for parents to wear when holding their baby. To make the kangaroo care experience more soothing, a harpist volunteered to come to the nursery weekly and play for parents and babies. The introduction of music into the SCN further promoted a healing environment and resulted in stress relief for both parents and the nursing staff. Through ongoing nurse mentorship, the Family Advisory Council has successfully implemented positive changes to the quality of care provided in the Special Care Nursery. Nurses are now more fully engaged in promoting the principles of family-centered care. The mission statement of the Family Advisory Council reflects the importance of nurses working with families to improve the quality of care: “Building a partnership between families and the Special Care Nursery team that supports excellence in family-centered care.”

Increasing Breastfeeding Assistance Through Education Breastfeeding provides multiple health benefits for newborn infants, including a reduction in infections (ear, gastrointestinal, respiratory), necrotizing entercolitis and sudden infant death. Breastfeeding mothers show less postpartum anxiety and depression, as well as more fat loss and an earlier return to their pre-pregnancy weight. Additional maternal health benefits include reduced risk of breast, uterine and ovarian cancer, as well as a decreased risk of developing osteoporosis. In 2010, the Labor and Delivery Research Committee at Rex Healthcare reviewed baseline data that indicated labor and delivery nurses, many of whom have more than 10 years’ experience, could do more to encourage breastfeeding in the first hour after delivery.   The purpose of the study was to determine if a breastfeeding education program would increase the number of times that labor and delivery nurses offer to assist mothers with breastfeeding within the first hour of life. Surveys were given to the nurses before and after the educational program. The outcome of the study showed that after a breastfeeding educational program the number of nurses that offered breastfeeding assistance within the first hour of life increased to 88 percent. This was found to be significantly higher than before the education (p = 0.0002).

Liz Massey, R.N., B.S.N.; April Lalumiere, R.N., B.S.N.; Laura Priest, R.N., B.S.N.; and Mary Kelly, R.N.

Expanded Lactation Support In 2012, Lactation Services expanded to include evening and night services to breastfeeding mothers. Assistance increased to seven days a week from 8:30 p.m. to 1:30 a.m. Since then, the exclusive breast milk rate has consistently remained above 50 percent as opposed to 40-45 percent from 2010-2011. All lactation consultants at Rex are board certified lactation consultants and registered nurses. These consultants, in addition to having a specialty in breastfeeding, have physical assessment and critical thinking skills to pick up subtle changes in the newborn. Most of them have prior experience in NICU, newborn nursery, post-partum or labor and delivery. They have noticed a variety of problems such as cardiac anomalies, seizures and cleft palates that were discovered during their observations of feedings. In 2012-2013, they provided more than 24,000 consultations to both inpatient and outpatient mothers. In addition to daily consults, they developed breastfeeding education modules to increase the staff’s knowledge and assistance to these mothers. Forty percent participate in the clinical ladder program for nursing.

A New Cardiac Intermediate Care Unit Open A unique opportunity arose when 3East opened as a new cardiac intermediate care unit in January 2011. Experienced staff nurses on that unit developed a strategic plan to provide comprehensive education to the large number of novice nurses that were hired. Strategies included the creation of a “Teach Me Tuesday” structure to enhance patient safety and information sharing. Sessions last 15-20 minutes and occur every Tuesday at 7 a.m. to include both night and day shift nurses. Policies/processes are reviewed or speakers are invited to deliver short in-services. A more formal class, “Cardiac Construction 101” was developed to help new nurses fill their “tool box” with tools to care for complex patients. Four specific frameworks were presented: SBAR, Change in Condition, Chest Pain, and Shortness of Breath. Experienced staff nurses were empowered and allocated time to develop and teach this class. In addition, “Third Thursday” complex case studies are reviewed on a quarterly basis.

Success was measured through program evaluations and scores from our Co-worker Satisfaction Survey. Data demonstrated department nurses rated the level of training they received to aid in performing their job, and the opportunity to improve their skills, at the 99.4 excellent percentile, as compared to the hospital which ranked at the 82.2 excellent percentile. The expert staff nurses (Renée Pouliot Bridges, R.N., B.S.N., P.C.C.N.; Donna Herrin, R.N., B.S.N., P.C.C.N.; Tina Swart, R.N., B.S.N., P.C.C.N.; and Mary Toma McConnell, R.N., A.D.N.) who developed this plan presented their strategy at the 2012 National Magnet Conference and were published in The Journal of Continuing Education in Nursing - Vol 45, No 2, 2014.

Creating an Innovative Structure to Support Best Practice in Novice Nurses o rk mew a r F

Change In Cond ition

Change in condition noted

Strategies include

the creation of a “Teach Me Tuesday” structure to enhance patient safety and information sharing. Sessions last 15-20 minutes and occur every Tuesday at 7AM to include both night and day shift nurses. They appreciate this consistent day and time for learning. Policies/processes are reviewed, or speakers are invited to deliver short in-services.

Topics for “Teach Me Tuesday” sessions Medication

• Medication Reconciliation • Effient and Insulins • Cardiac Medications • Tikosyn • Dobutamine and Heart Failure • Pharmacy Concierge Service • Anticoagulants

Initial Survey

Notify Charge RN and stay with patient

Subjective

Assess

Follow existing orders

Plan

No orders from physician

Continue with ongoing assessment and communication

A more formal class, “Cardiac Construction 101” was developed to

help new nurses fill their “tool box” with tools to care for complex patients. Four specific frameworks were presented: SBAR, Change in Condition, Chest Pain, and Shortness of Breath. Experienced staff nurses were empowered and allocated time to develop and teach this class.

Rex Healthcare Raleigh, NC

Presenters: Renée Bridges, R.N., B.S.N., P.CC.N. • Donna Herrin, R.N., B.S.N. • Tina Swart, R.N., B.S.N., P.C.C.N. • Co-author: Mary Toma McConnell, R.N. Contact information: Renée Bridges, R.N., B.S.N., P.CC.N. (919) 784-3108 renee.bridges@rexhealth.com

• SBAR Report • CIWA Protocol and Documentation • Documentation of Blood Products and Vaccines • Pre-Procedure Paperwork

Tools of the Trade

• Update on Improving Heart Failure Outcomes Study • Heart Failure Trial Pathway • Heart Failure Education

• Cardiac Catheterization Closure Devices • Life Vest • EKG • Safe Lifting • Hi-Flow Nasal Cannula

IV Care

Nursing Professionalism

Heart Failure Objective

Documentation

• IV Pump Problem Shooting • Curos caps for PICC Lines • Flushing lines and HIT • Line Reconciliation • Ports

Nursing Care

• Re-think Pain Management • Hypoglycemia • Care of the Pneumonia Patient • Uninsured Population • Stroke

• Interdisciplinary Rounds • Joint Commission Wheel of Fortune • Managing Stress • Service Recovery

Sessions presented by

• Staff Nurses from Home Unit • Specialty Area Nurses • Clinical Nurse Specialist • Clinical Nurse Educators • Clinical Documentation Specialist • Specialty Physicians • Pharmacists • Respiratory Therapists • Product Representatives

Success has been measured through program evaluations and

scores from our 2011 Co-worker Satisfaction Survey. Data demonstrated department nurses rated the level of training they received to aid in performing their job, and the opportunity to improve their skills, at the 99.4 excellent percentile, as compared to the hospital which is ranked at the 82.2 excellent percentile.

References:

1. Brier, J., Moalem, C., Haverly, M., Januario, M., Tal, A., and Tirosh, H. (2011). Defining Vital in Vital Signs Monitoring and Patient Surveillance: Development of an Algorithm for Nursing Surveillance. 2011 ANCC National Magnet Conference. 2. Institute for Healthcare Improvement. (2011). SBAR: Situation-Background-Assessment-Recommendation. http://www.ihi.org/explore/ SBARCommunicationTechnique/Pages/default.aspx.

The best teamwork comes from men who are working independently toward one go

Recognized and Chosen for Excellence • Named a “Top Performer” by the Joint Commission Annual Report • National Research Corporation recognized Rex with its Consumer Choice Award for the 10th consecutive year. Rex is the only hospital in Wake County to earn the 2013 award and one of only ten recipients in North Carolina. • Honored as one of the country’s “100 Great Hospitals” by Becker’s Hospital Review, Rex is the only hospital in Wake County to receive the designation in 2013. • Named one of the top 50 N.C. Family-Friendly Companies by Carolina Parent Magazine in 2013, earning that recognition 15 consecutive times. • Rex Healthcare was honored with an “A” Hospital Safety Score by The Leapfrog Group in 2012 and 2013, and in the Fall 2013 Hospital Safety Score update.

North Carolina Great 100 Nurses 2012 – Donna Herrin, B.S.N., R.N., P.C.C.N.               Leanne LeClair, B.S.N., R.N., C.P.A.N. 2013 –   Jacqueline Murphy, B.S.N., R.N.               Helene Zehnder, M.S.N., R.N., N.E.-B.C., P.C.C.N.

Sarah Hitchcock Leinster Nursing Excellence Award 2012 – Jacqueline Murphy, BSN, RN 2013 – Judy Grider, RN, ADN

Shared Governance Council Chairpersons Nursing Council

2012

2013

Nursing Congress

Beth Shehzad, R.N., B.S.

Helene Murphy, R.N., B.S.N.

Professional Development

Katoya Wright, R.N., B.S.N.

Katoya Wright, R.N., B.S.N.

Quality Improvement Cheri Clay, R.N., A.D.N. Council Clinical Informatics Council

At Rex, we believe that high-quality health care means more than providing exceptional medical treatment; it means providing care by skilled professionals who care - people like you. When you pursue a career at Rex, you’ll be part of an awardwinning team that genuinely cares about you and your family’s needs and goals so that you can better care for our patients. You’ll discover an environment that emphasizes respect and innovation – one that is recognized in our community and beyond for caring and commitment to excellence.

Tara Oxendine, R.N., A.D.N.

Anna Pellegatta, R.N., A.D.N., Lindsey Corbett, R.N., C.M.S.R.N. B.S.N.

Nursing Research Jessica Collins, R.N., B.S.N. & Innovation

Ramonita Rodriguez-Begley, R.N., B.S.N.

Clinical Practice Cathy Miller, R.N., B.S.N. Council

Renee Bridges, R.N., M.S.N., P.C.C.N.

oal in unison. - James Cash Penney

Careers at Rex

For more information on how you can become part of our team, visit rexhealth. com/careers today.

4420 Lake Boone Trail Raleigh, NC 27607 rexhealth.com