2016 Nursing Week - BPG Sustainability Virtual Poster Gallery

2016 Nursing Week BPG Sustainability Virtual Poster Gallery

Reducing Falls and Falls with Injury Cindy Pablo RN, Susan Camm, RN, MHSc, CLM, Shirley Bell, RN, BSc(N), Clinical Nurse Educator, Tasha Ferron, RN St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS

• Reducing falls and injury from falls on General Internal Medicine (GIM) • Implement intentional rounding at key times when the majority • of falls happen • Incorporate falls prevention into patients’ care plan

Plan

Do

RESULTS

•Draft project timeline •Consult key stakeholders •Study fall reports as per reason, place and timing of falls •Investigate how intentional rounding and care plans can be accomplished on unit.

Average Falls Rate Pre Intentional Rounding is 9.62 per 1000 patient days Average Fall Rate Post Intentional Rounding is 7.7 per 1000 patient days

Study

“Address Patient Needs”

•RN and Clinical Nurse Educator visited General Surgery Inpatient Unit to see how intentional rounding was done.

•On August 9th 2015 tools and flow sheets were developed and intentional rounding was started on nights first, then on days at 1300 and 1600.

•Falls Risk Collaborative Care Plan, developed by QIP Working Group rolled out on unit on January 18th 2016

Overall Falls Decreased by 20%

BACKGROUND • Average fall fate on GIM (2014/15) was 17 patients a month

“Works Great” “Safer for Patients”

•Group huddles done each night, led by Charge Nurses, looking for feedback on intentional rounding tools and process •Falls Risk Collaborative Care Plan reviewed by staff

Most falls happened at these times:

1400 2400 to 0600

1800 & 1900

Act

•Intentional rounding tools modifications as per staff feedback. (PDSA cycle times 5) •Timing of intentional rounding changed to 1330 and 1630 on days to accommodate workload demands as per staff feedback •Falls Risk Collaborative Care Plan revised by QIP Working Group

RN Rounding Huddle

CONCLUSION •

Falls

Intentional Rounding Report Sheet •

•

Average Overnight Falls Rate Pre Intentional Rounding is 3.7 per 1000 patient days Average Overnight Fall Rate Post Intentional Rounding is 2.3 per 1000 patient days

Studies indicate that patients who did not have a fall while in hospital were 2.4 times more likely to be discharged earlier from acute care than patients who had a fall.

RECOMMENDATIONS/NEXT STEPS

• Current care plan does not include: • fall risk behaviors • patient specific intervention or strategies • information about patient’s fall date in hospital

Overnight Falls Decreased by 38%

PURPOSE & OBJECTIVES • • • •

Decrease falls and falls with injury by 10% on GIM Goal of 70% compliance rate for completion of care plan Engage staff in dialogue about falls Improve patient safety

Fall Risk Collaborative Care Plan Instructions: RN to initiate on admission for patient assessed as Falls Risk on (Soarian). RN and Inter-professional team to update with changes in patient’s condition.

Fall Risk Behaviors Check all that apply/observed

INTERVENTION/PROCESS Intentional rounding: RN and CA pair up in groups assigned and round on patients hourly with the intent of looking at Pain, Potty, Positioning and Personal Needs. RN then documents that intentional rounding was done.

Equipment: Implement low beds, beds with alarms, and floor mats to decrease fall injury

Care Plans: Revision of care plans to include date of fall (if applicable) and falls prevention strategies

•

A decrease of 17% of fall rate is mostly represented on night shift, which could be related to the increased intentional rounding compliance Attending to patient’s basic needs during intentional rounding (e.g. Toileting) may have decreased the number of falls With increased awareness and education about care plans, compliance increased by 7%

Date of last fall:______________  History of Falls  Not calling for help  Forgetful/Confused  Climbing out of bed/chair  Unsteady gait/weakness  Lack of insight into physical limitations  Incontinence/frequent urination  Hungry/looking for food  Others

Patient Specific Strategies

Focussed Rounding: 14CC protocol Show back for call bell Involve other team members Minimize clutter Place Gait Aid/commode at beside Leave bathroom light on Ensure patient teaching  Need low bed? – email Jennifer Goss to request  Need floor mat?- email Jennifer Goss to request  Assess for bed alarm (on low bed)  Reassess Foley catheter  Reassess medications (e.g. lasix)  Toileting Routine: Q ___ Hour  Consults:

Falls Risk Collaborative Care Plan Compliance (Target = 70%)

Specific:

60.00%

• Do mini booster sessions on intentional rounding to keep momentum going • Continue to audit compliance rate for care plans • Consider sustainability strategies for daytime intentional rounding • Identify and recruit more champions • Re-design kardex to incorporate Falls Risk Collaborative Care Plan onto the front

REFERENCES RNAO. (2002). Prevention of Falls and Fall Injuries in the Older Adult. Best Practice Guidelines, Revised 2005. p.g 1-91.

50.00%

ACKNOWLEDGEMENTS

40.00% 30.00%

Colleen McNamee, Corporate Nursing Education Leader, QIP Working Group, Gregory Arbour, Quality Improvement Specialist

20.00% 10.00% 0.00% February 5th

February 15th

March 14th

Transfer of Accountability Between TNICU and Emergency Denbok J1, Kokoski C1, McGowan M1, Blight A2, Bakker A2, Barratt L1, Govan V1, Paramalingam V2, Doherty AM1, Gaunt K1, Butorac L2 1 Emergency Medicine, St. Michael’s Hospital 2 Critical Care, St. Michael’s Hospital

INTERVENTION/PROCESS

FOCUS • • • •

Improving transition of care between TNICU and Emergency Identify barriers to effective Transfer of Accountability Increase patient safety RNAO best practice guideline supporting focus: • Care transitions • Professional Practice

BACKGROUND • Nurses as the frontline care providers have a unique role in providing continuity of care for these patients, though the fast-paced and stressful nature of these admissions generates many barriers to providing a smooth and detailed transfer of care • Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs.

One study estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers (Joint Commission, 2012) • Lack of standardized tool between TNICU and ER for handover can cause ineffective communication

RNAO BPG recommendations: •2.2 Use effective communication to share client information among members of the interprofessional team during care transition planning.

•3.2 Use standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions

PURPOSE & OBJECTIVES • To re-examine the handover process between ED and TNICU nurses in order to improve communication and facilitate a standardized approach to transfer of care for all trauma and neurosurgical patients requiring ICU care.

RESULTS

• As part of a quality improvement initiative, Registered Nurses from both the ED and TNICU answered a 5-question open-ended survey to elicit understanding of perceived concerns, stressors and gaps in the ED to TNICU transition process • Created a a skeleton checklist as a standardized tool through between TNICU and ER

collaboration

•

36% usage 3 months after implementation

•

Secondary survey results showed: • 85% found the tool helpful in communication • 30 out of 37 elective responses on how to increase numbers said accessibility was a problem • Feedback from staff showed no need to change format of tool

• Provided teaching to staff for one month with face to face sessions and reached 70% of staff before implementation.

• Sent email with video of examples of TOA using checklist to reach those who did not receive teaching • At 3 months post implementation created an thematic questionnare to evaluate sustainability

RECOMMENDATIONS/NEXT STEPS

TRACKING CHANGE • •

The tool is barcoded and included as part of the chart to monitor uptake Signatures of both staff are required on TOA tool facilitating easy follow-up on use/benefit 70 60

• •

Data collection for the amount of times tool used for all patients transferred between TNICU and ER Created reward system for usage called “TOA ‘s Top Ten”. Draws for gift card for every tenth tool used.

• Created more accessibility and awareness of tool to increase uptake as per secondary survey results.

• Review tool with staff reinforcing education •Share usage and survey results with staff •Increase accessibility by putting folder by elevator in emergerncy room and a TOA tower in TNICU • Reward system created called “TOA’s Top Ten” with a draw for every tenth tool used for gift card

50 40 30 20 10 0 USED TOOL

DID NOT USE TOOL

TO OR

DIRECT TO TNICU

CONCLUSION •Preliminary themes highlight the importance of communication and collaboration at a time of uncertainty, including sharing injuries and care plans among disciplines and professions, to enhance patient safety, reduce healthcare provider stress, while supporting smooth transitions.

•These findings were used to develop an ED-TNICU transfer of care tool to support and guide sharing of information critical to the care of the trauma patient or critical neurosurgical patient. The tool design reflects actual situations and ER and TNICU nursing input. A collaborative education program was developed between the EDTNICU to implement the tool.

REFERENCES •RNAO (2014) Care Transitions. http://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf •Starmer et al., (2012) I-PASS, A Mnemonic to Standardize Verbal Handoffs. http://pediatrics.aappublications.org/content/129/2/201 •Bigham et al., (2014) Decreasing Handoff-Related Care Failures in Children’sHospitals.http://pediatrics.aappublications.org/content/pedia trics/134/2/e572.full.pdf •Boat & Spaeth (2013) Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. http://onlinelibrary.wiley.com/doi/10.1111/pan.12199/abstract •Joint Comission (2012) Transitions of Care: The need for a more effective approach to continuing patient care. http://www.jointcommission.org/assets/1/18/hot_topics_transitions_of _care.pdf

ACKNOWLEDGEMENTS Thank you to the staff in TNICU and ER for partaking and shaping the TOA tool to create sustainability and increase quality of care

Managing Violence & Responsive Behaviours: Flagging Procedures Joanne Le, RN, BScN, CNN(C) St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS

INTERVENTION/PROCESS

•

1.

•

• •

Standardizing a method for communicating safety-related concerns for staff and visitors Formalizing a risk assessment and care planning strategy for patients who are experiencing responsive or violent behaviours Promoting the safety of patients and staff by increasing awareness of known risks and triggers In correlation with Registered Nurse’s Association of Ontario BPG: Crisis Intervention

BACKGROUND • Violence occurs most frequently in the healthcare setting, 30% of reported violent incidents in Ontario originating from this sector. (PSH&SA Flagging toolkit, 2015) • Being assaulted at work also has repercussions for families, co-workers, and the quality and productivity of healthcare (PSH&SA Flagging toolkit, 2015) • Currently no formal screening and prevention program for Violence or Responsive behaviours on the Trauma/Neurosurgery In-patient Unit • Related recommendations from BPG: Crisis Intervention: • 6.0 Nurses are directly involved in all aspects of crisis intervention • 7.0 Teaching and educating clients, families, colleagues about crisis intervention and prevention are essential to promote health

PURPOSE & OBJECTIVES Purpose: To implement a standardized identification and management program for patients exhibiting violence, potential for violence, and responsive behaviours.

Objectives: • > 80% of FT/PT RNs on 9CC will receive education on flagging procedures, measured through staff attendance at an education session •Target compliance of > 60% of patients being assessed for risk of violence and/or responsive behaviours measured by chart audits •Obtaining positive staff perception post implementation gathered through staff feedback •Obtaining patient and family acceptability of the program through a brief interview

•

CONCLUSION

Development of tools: - Responsive Behaviours Assessment Tool (RBAT) used to evaluate risk behaviours for impending violence or responsive behaviours - Flag placed in front of the patients door and used to identify a potential safety risk - Safety care plans help describe and identify individual triggers and interventions RBAT = 4 PDSA cycles, Flag = 3 PDSA cycles Safety care plan = 3 PDSA cycles, and is still a work in progress

2. Flagging Procedures Education inservices ~30 mins • Providing staff (RN’s, CA’s, health disciplines) education regarding flagging procedures; managing responsive behaviours, reviewing interventions and de-escalation techniques, and trial run of the tools using a mock scenario 3. Flagging Procedures Unit Resource • One week designated to support the uptake of the program, answering questions, gathering feedback, support in completing assessments, and reinforcing expectations

Bed # ___ Please check with the Nurse before entering

RESULTS Education sessions •65/74 (88%) of RNs received education (Target was 80% of RNs) • > 10 health disciplines (NPs, Dieticians, SLPs, PTs, SCWs) •17/26 (65%) of CA’s Compliance rate •Random chart review showed 76% compliance rate with completion of RBAT (Target 60%) – February 22, 2016 •5 patients met criteria for being moderate to high risk of violent/responsive behaviours • 4/5 had safety care plans • 5/5 of patients had flags Positive Feedback: •“ I think this is good, we needed something like this to protect us and also the patients.” – Nurse D •“ I really like this, especially with intentional rounding. I may not know the patient I am rounding on and therefore it increases my awareness.” – Nurse C •“It’s more work, but it’s important”. – Nurse S •“Some people are great with my son, however some people are not.

If this is to help communicate care strategies that work for him, then I’m all for it.” – patients father

•The utilization of the RBAT led to flagging 5 patients that were exhibiting violent or escalating responsive behaviours and prompted the development of a safety care plan for the patients •Having a resource on the unit for one week to support staff in completing the tools positively affected early implementation and compliance of the flagging program •Uptake of the program so far has been positive, as reflected through staff and family feedback •Aligning the initiative with the strategic priorities of professional practice and key stake holders are crucial to the development and sustainability

RECOMMENDATIONS/NEXT STEPS • Obtaining validation of the tool • Continuing chart audits and feedback of compliance data • Informing other members of the team including Environmental services, volunteers, phlebotomists, Medical Radiation technologists • Obtaining feedback from a larger group of RNs and patients/families after one-month of implementation • Electronic charting of RBAT

REFERENCES Registered Nurses Association of Ontario (2002). Crisis Intervention.

Toronto, Canada: Registered Nurses Association of Ontario, retrieved from www.rnao.org/bestpractices Public Services Health & Safety Association (2015). Flagging Toolkit.

Toronto, Canada: Public Services Health & Safety Association, retrieved from http ://www.pshsa.ca/wpcontent/uploads/2015/05/Flagging-Draft-Toolkit.pdf

ACKNOWLEDGEMENTS Mary Copeland, RN, Clinical Lead Manager, Neurosurgery/ Trauma In-patient Unit Kayleigh Faulkner, RN, MN, Clinical Nurse Specialist, Neurosurgery/Trauma ICU Colleen McNamee, RN, MN, Corporate Nursing Education Leader Natalie Ford, Health, Wellness, & Safety Specialist, Corporate Health

Abuse Screening in the Ambulatory Mobility Clinic Josephine Rockman RN, BScN, Mari Vella MSW, RSW, Ines De Campos RN, MSc St. Michael’s Hospital

PROCESS (con’t)

FOCUS

PURPOSE & OBJECTIVES

To implement a standardized process of abuse screening in the Fracture Clinic of St. Michael’s Hospital

• To develop a screening tool to be given to every patient at every visit, responsive to the needs of patients, capturing any safety concern

This BPG initiative was informed by the following recommendations from the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline (BPG) Women Abuse Screening, Identification & Initial Response: 1.0 Nurses implement routine universal screening for woman abuse 2.0 Routine universal screening be implemented for all females 12 years of age and older 3.0 Nurses develop skills to foster an environment that facilitates disclosure 4.0 Nurses develop screening strategies and initial responses that respond to the needs of all 5.0 Nurses use reflective practice to examine how their own beliefs, values, and experiences influence the practice of screening.

6.0 Nurses know what to document when screening for and responding to abuse 7.0 Nurses know their legal obligations when a disclosure of abuse is made 8.0 Mandatory educational programs in the workplace be designed to: increase nurses’ knowledge and skills; and foster awareness and sensitivity about woman abuse.

BACKGROUND • The objective of the St. Michael’s Hospital 2011 Quality Initiative program was to raise awareness of abuse and impact of violence on our Ambulatory Orthopedic patients • Statistics revealed 25% of St. Michael’s Hospital Fracture Clinic patients suffered abuse at home (Bhandari et al., 2011) • No formal process in place in the Fracture Clinic to assess patient safety at home in regards to an abusive setting • A formal screening process was developed and implemented in 2010 in St. Michael’s Hospital Emergency Department as part of the implementation of RNAO BPG Women Abuse Screening, Identification & Initial Response

RECOMMENDATIONS/NEXT STEPS • Starting in Spring 2016, every patient will receive the screening assessment during their Fracture Clinic appointment • Continue to provide education and resources for staff to create an environment that facilitates disclosure and supportive care

• Increase awareness and knowledge of Abuse Screening Pathway, including the legal obligation when a disclosure of abuse is made

• Capture abuse screening completion rates and # of referrals of an identified case through random audits

• Creating a safe environment where patients feel comfortable to disclose their experience

• Report metrics back to staff using the Outpatient Mobility Care Utilizing Evidence (CUE) Dashboard

• To ensure all staff are aware of hospital and community resources to support patients disclose abuse

• Abuse screening pathway to be re-evaluated by the Fracture Clinic team on a quarterly basis

• Ensure a TOA from the Emergency Department to the Fracture Clinic for patient’s who are screened ‘yes’ for abuse

REFERENCES

PROCESS •

Sprague S, Goslings JC, Petrisor BA, Avram V, Ayeni OA, Schemitsch EH, Poolman RW, Madden K, Godin K, Dosanjh S, Bhandari M, (2013).Patient Opinions of Screening for Intimate Partner Violence in a Fracture Clinic Setting Journal Bone Joint Surgery American 95:13

•

O’Campo, P, Kirst, M, Tsamis, C, Chambers, C, & Ahmad, F. (2011).

Implementing successful intimate partner violence screening programs in health care settings: evidence from a realist-informed systematic review. Social Science and Medicine, 72(6), 855-866.

•

Registered Nurses’ Association of Ontario (RNAO). (2005). (Revised 2012).

Woman Abuse: Identification, screening and Initial response. Toronto, Canada: Registered Nurses’ Association of Ontario.

•

Bhandari M, Sprague S, Dosanjh S, Petrisor B, Resendes S, Madden K, Schemitsch EH, PRAISE Investigators. (2011). The prevalence of intimate partner violence across orthopaedic fracture clinics in Ontario. J Bone Joint Surg Am. 93: 132-141.

•

College of Nurses of Ontario, (2016) Abuse Prevention: One is too many Retrieved from http://www.cno.org/en/learn-about-standardsguidelines/educational-tools/abuse-prevention/

Staff questionnaire to assess knowledge base & comfort level

In-service for staff based on needs identified ST. MICHAEL’S HOSPITAL IS CONCERNED ABOUT

Staff educated on abuse screening pathway for Outpatient Mobility Program

Develop abuse screening tool

Posters displayed in patient and staff areas Additional resources provided to staff to support a positive patient disclosure Social Work liaison between Ambulatory Program and Emergency

YOUR SAFETY IN THE HOSPITAL AND AT HOME

Figure 2. Abuse Screening Pathway – Mobility Program

Please answer the following questions: YES

NO

Do you feel safe at home?





Is your visit today a result of an unsafe home setting?





Would you like to speak to a healthcare professional about this issue today in a private room?





NEED HELP MAKING A SAFETY PLAN? Call the Assaulted Women’s Helpline: 1-866-863-0511 or 416-863-0511 Or Victim Services Toronto 416-808-7066 To get more information on how to make a safety plan

Figure 1. Abuse Screening Tool

LESSONS LEARNED • Role playing is a helpful technique to increase staff comfort level with engaging patients in conversations about their safety at home • Staff’s personal experiences with abuse may impact their ability and comfort level to screen patients for abuse and they may require additional coaching and support • Creating a safe and supportive environment for staff to ask questions and voice concerns is critical to uptake • Approaching staff in one on one sessions provided the opportunity to discuss concerns and reduce stress associated with the adoption of the new screening process • Seek opportunities to align resources with other department quality and research initiatives

ACKNOWLEDGEMENTS • • • • • • • • •

Esther Carter RN Christopher Streit R.T. (Ortho) Katherine Skrabec R.T. (Ortho) Niko DaSilva, Jo-Anne Harris, Nichola McLean Caroline Jones BSc MScPT Angelo Papachristos BScPT MBA, Rachel Yantzi RN BSN, MN Patricia O’Campo PHD Nursing Professional Practice at St. Michael’s Hospital

Enhancing ED/14CC Transitions in Care of Patients with Observation Needs Mary Clark, RN, MN; Susan Camm, RN, MHSc, CLM St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS Enhancing ED/14CC Transitions in Care and Management of Patient High Observation Needs on 14CC. Focus of Best Practice Guidelines 1. Client Centered Care 2. Building therapeutic relationships with patients

INTERVENTION/PROCESS Process

Intervention

Who: *CN staff survey to determine information required 14CC Charge Nurses & ED to transition ED patients requiring constant (end of RN’s Jan 2016).

RESULTS

CONCLUSION

Pre Implementation Charge Nurse Survey Results (n=23)

• The process change improved charge nurses’ level of awareness about the needs of the patients prior to coming to 14CC, particularly the need for constant care provider

• 100% CN surveyed need more information on patients requiring constant.

• 100% find it challenging to find a bed for patients on constant.

*Informal education with CN (5 min sessions) *Meet with ED champions (Carolyn & Victoria) to establish communication, ED needs and collaboration.

BACKGROUND

* Create reminder for ED computers prompting reason for constant order & email ED clericals introducing project.

Opportunity Statement: • Delays in transitioning patients from ED to 14CC especially for patients requiring constant observation.

• Gap in knowledge translation of patient needs prior to transfer to the unit (ToA).

• Gap in developing therapeutic relationships and engaging patients in their care.

Supportive Evidence:

Why & Who Ordered Constant

How: Gain knowledge of patients requiring constant/sitter to transition them from ED to 14CC efficiently.

Establish therapeutic relationship with patient in ED requiring constant.

Strategies Used in ED

• By seeing patients in ED we prevented the use of constant care providers when they could be managed with other interventions Behaviours

14CC CN goes to ED or calls to ToA with ED RN. Self Audit commences Feb 6, 2016.

Creation of prompting tool for ED on resources on 14CC to manage behaviours (i.e. locked area, fall mat etc.) (Feb 2016)

RECOMMENDATIONS/NEXT STEPS Figure 2: Pre Implementation Survey indicating the information staff wants to know in report (Three responses were equally selected by staff) (n=23)

Education for physicians about resources on 14CC to manage patient behaviour other than constant.

# Patients with Ordered Constant Provider

ToA in ED or by phone

Modification in Soarian to include reason for constant as a requirement to enter the order

6

5

Audit Dates

14CC CN meets patient & explains plan, initiates “My Story” when family available.

02/18/16 - 02/23/16 03/09/16 - 03/18/16

• Literature review reveals patients want to be involved in their care and those that are have better health outcomes (Leach, 2005).

Assess need for booster education sessions.

Figure 3: Audit Results for Number of Patients with ordered constant care and instances where TOA occurred in ED/phone between CN & ED RN

• Literature suggests that including patients in planning shows you value them, fostering therapeutic relationships and are promoting positive patient behaviours (RNAO, 2014).

Ongoing assessment of staff progress, satisfaction and engagement.

Post Implementation Staff Survey (n=16) 100%

• Literature suggests ToA can improve the quality of the clinical information and allow for planning, promoting patient safety.

REFERENCES

90% 80%

Leach, M.J. (2005). Rapport: A key to treatment success.

Complementary therapies in Clinical Practice, 11(4), p.262-265. doi:10.1016/j.ctcp.2005.05.005

70% 60%

PURPOSE & OBJECTIVES

50% 40%

Goals & Measures:

RNAO. (2014). Establishing therapeutic relationships. Best Practice Guidelines, February 2014, p. 1-62.

30%

• To enhance the transition of observation patients from ED/14cc by utilizing early ToA (charge nurse going to ED or calling) 90% of the time by April 2016.

• To build therapeutic relationships by meeting patients in ED and encouraging participation in “My Story”.

• The process change also has preliminary impact in: • potentially improving relationship between ED & 14CC • developing a therapeutic relationship with the patient and preparing patient for transfer to 14CC, thus easing patient’s transition from ED to 14CC • improving accountability of clinician in assessing patient’s risk of harm and the need for constant care provider

20% 10%

ACKNOWLEDGEMENTS

0%

Figure 1: Prompting tool for computers in ED

Improved accuracy understanding of needs

Build therapeutic relationship

Helps assign a bed

Figure 4: Proportion of RNs who answered YES to survey items

Cecilia Santiago, RN, MN, CNCC(c), Mentor Shirley Bell, RN, BScN (c), Educator

To A Better Care Transition Maria Laylo, RN; Zeinab Yusuf, RN; Beatriz Rondon, RN; Charmaine Mothersill RN, MN, CLM St. Michael’s Hospital

BACKGROUND

METHOD

INTERVENTION

11 RNs participated in baseline survey and interview on: According to studies, 70% of adverse events are due to miscommunication between healthcare professionals (JCAHO, 2003).

RNAO recommends the use of “standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions” (RNAO, 2014).

CONCLUSION & NEXT STEPS ● Effective handover communication is key in the delivery of effective patient-centered care.

● perceptions and attitudes regarding communicating senior friendly information during TOA ● effectiveness of current TOA tool and Patient Care Plan

● The development of unit specific TOA tool and Patient Care Plan will facilitate accurate exchange of information between RNs ● The next step is to further evaluate the revised tools with the continued support of stakeholders and staff.

FINDINGS

REFERENCES

Transfer of Accountability (TOA) tool is used to ensure complete and accurate transfer of patient information between RNs during change of shift (Alvarado et al., 2006).

Alvarado, K., Lee, R., Christoffersen, E., Fram, N., Boblin, S., Poole, N., Lucas, J., & Forsyth, S. (2006). Transfer of accountability: Transforming shift handover to enhance patient safety. Healthcare Quarterly, 9, 74-79.

TOA identifies safety concerns, ensures continuity of care (Alvarado et al., 2006), and improves handover efficacy (Klim, Kelly, Kerr, Wood, & McCann, 2013).

JCAHO. 2003. “ Sentinel Events Statistics” [announcement]. March 31. Joint Commission on Accreditation of Healthcare Organizations site 165-2005. Retrieved March 30, 2016. <http://www.jointcommission.org/SentinelEvents/Statistic>

Evaluation of current TOA processes and practices revealed that shift handover tools (TOA and Patient Care Plan) lack unit specific assessments and senior safety components.

Klim, S., Kelly, A., Kerr, D., Wood, S., & McCann, T. (2013).

Developing a framework for nursing handover in the emergency department: an individualised and systematic approach. Journal Of Clinical Nursing, 22(15/16), 2233-2243. doi:10.1111/jocn.12274

Integrating senior safety components in TOA communicating tools will facilitate the development of comprehensive care plans catered to the needs of seniors. Ultimately, this will improve patient overall function and well-being.

Poh, C. L., Parasuram, R., & Kannusamy, P. (2013). Nursing inter-shift handover process in mental health settings: a best practice implementation project. International Journal Of Evidence-Based Healthcare (WileyBlackwell), 11(1), 26. doi:10.1111/j.1744-1609.2012.00293.x Registered Nurses Association of Ontario. (2014). Clinical Best Practice Guidelines: Care Transitions. Retrieved from: http://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf

OBJECTIVES To enhance RN-to-RN communication by incorporating the following in TOA tool and Patient Care Plan:

ACKNOWLEDGEMENTS

● Feedback from staff RNs ● Senior Friendly Initiative strategies Figure 1 Senior Friendly Initiative prompt sticker to be placed in Patient Care Plan

Special thanks to Rosemarie Rivera (Clinical Nurse Educator), Cecilia Santiago (Mentor), and 2 Donnelly RN Staff for their contributions to the development of this project.

Enhancing Transfer of Accountability Between General Internal Medicine and Emergency Department Magetta Vincent RN, BScN, Susan Camm RN, MHSc, Shirley Bell RN, BScN(C), Kim Grootveld MSc QI(C) St. Michael’s Hospital, Toronto, Ontario, Canada

INTERVENTION/PROCESS

FOCUS

RESULTS

Enhancing transfer of accountability (ToA) between General Internal Medicine (GIM) and Emergency Department (ED) to support patient flow and improve RN to RN communication between ED and GIM

Interviews: • 4CC interviews (n = 30) Surveys: • Pre survey • Post survey

RNAO BPGs: 1. Patient and Family Centred Care 2. Professionalism in Nursing (PIN) 3. Establishing Therapeutic Relationship (ETR)

Meeting with ED ToA Task Force: • Revisited previous • Existing ToA tools reviewed

BACKGROUND • • • • •

Patient’s length of stay in ED is a critical challenge for Ontario Hospitals (Health Quality Ontario, 2012).

Delays in transfer to the General Internal Medicine unit (GIM)) at St. Michael’s Hospital occurs daily.

GIM patients represent 40% of all admissions through ED with 95% of all admissions in GIM originate in the ED. So any improvement or change made will impact both units.

Inconsistent ToA between ED and 14CC has led to frustration and anxiety among nurse.

ToA methods tried in the past: • 2011 - faxed report • 2012 – written tool

Education Sessions: • 6-8 sessions • 8-10 RNs/session

CONCLUSION

Table 1: RNs’ perceptions and attitudes about conducting transfer of patients from ED to GIM

Pre-Survey (n=30) Agree

Post-Survey (n=90)

Disagree

Agree

Disagree

• •

GIM nurses should receive ToA within 15-30 min when “bed ready” and “nurse ready”

94%

6%

100%

0%

Calling 15 -30 minutes will improve timeliness of transfers

98%

2%

100%

0%

Information sharing about patient care between GIM and ED nurses could be improved

97%

• 3%

100%

0%

Multimodal Education: • PowerPoint • Interactive discussions

• Share the survey and audit results with GIM team.

• Conduct focus group sessions with RNs on how to sustain the modified tool in practice.

• Continue to conduct weekly audits to measure compliance and share the audit results with staff at each staff meeting.

• Share audit results and survey results with ED team.

• Continue to remind RNs on GIM to fill out their ToA tool ‘time bed ready’ and ‘time report given’.

GIM Nursing Transfer of Accountability Form (ToA) Day Shift Date:_____

OBJECTIVES

Patient’s Name: _______________________ Code Status: ____

1. To engage GIM RNs and ED RNs in redesigning the ToA process and modifying the existing ToA tool 2. To promote timely ToA between GIM and ED RNs 3. To elicit GIM RNs’ perception and experiences related to ED/GIM ToA Evaluation Measures

Indicators

Process

Nurse compliance rate to ToA report within 15-30 minutes when “RN ready” and “bed ready”

Data Collection Process Audits:

(M / F)

Age_____

Isolation Y/N Type: RCP____ Contact_____

Room:_____ Negative Pressure.____

Constant/ Frequent Observation Required: Y / N Reason__________

Safety Checks: Arm Band: Allergies: _________ Call Bell: Show back: IV Solution & Site: ______________ Oxygen: ______ Suction_____ Tracheostomy. Y N Suction Equipment:___________ Environment scan/fall risk___ side rails: _____Low bed____

Frequency Weekly

CAM: ___________ NHISS: _________ Continent Status: ________ I/O: _________ Pain Score: ________ Location: _________ Analgesic: _________ Time of last PRN: _______ Texas grading: _____________ Braden score/changes: _____________ My Story form Y N Telemetry__________

Labs:

Past Medical History:

Blood Glucose Levels:

Discuss patient’s current status: (significant findings from head to toe assessment)

Team:_____

Form 1: Y / N Reason_________

ED/14CC Admit Patient report:  Time Bed Ready _______________  Time ToA Received_____________  Time Patient Arrived____________ Medical Diagnosis:

“Bed-ready Time” “Time ToA given”

N /P Swab Y N

REFERENCE

Reason for delay: ___________________

Nursing Focus/Next Step:

Figure 3: Compliance rate of GIM RNs receiving ToA from ED RNs within 15-30 minutes from “RN ready” and “bed ready”.

NEURO -

Health Quality Ontario, (2012). Quality Improvement Guide.

Available from: http://www.hqontario.ca/portals/0/Documents/qi/qi-q

ACKNOWLEDEMENTS

Vital Signs -

“Time patient arrived to 14CC”

Understanding the existing ToA processes in ED was critical in making meaningful changes to the current one.

GIM RNs perceived that the revised tool has helped to ensure accurate and relevant information is communicated during TOA. The survey showed that majority of GIM RNs agreed that they should receive ToA within 15-30 minute when “bed ready” and “RN ready” and that this will improve the timeliness of patient transfer from ED to GIM. Following the education and awareness campaign, weekly audits revealed RN compliance rate to receiving ToA from ED within 15-30 minutes when “RN ready” and “bed ready” is 94-100%.

NEXT STEPS

Awareness Campaign: • Group emails • Staff meetings • Signs • Face to face

Figure 1: GIM RN receiving TOA from ED RN

•

RESP -

“The revised ToA tool is useful and provides a more focused approach”

CV GI -

Nurses attitudes and perceptions towards ToA

Outcome

Pre-implementation Interviews Pre-Post Staff Satisfaction Surveys

Interview Feb.9/16

MSK INTEG -

Pre-Survey

“The revised ToA form is more user-friendly”

GU -

Test Plan - _________

“The ToA tool is concise when capturing pertinent information”

Diagnostic Test - _______ PAIN CONTROL Discharge Date - _________

Feb. 9/16 Post-Survey Mar. 31/16

Figure 2: Revised ToA tool to include: 1) Time Bed Ready; 2) ToA Received; 3) Time Patient Arrived

Figure 4: GIM RNs’ comments about the revised ToA tool.

General Internal Medicine RNs Emergency Department RNs (Carolyn & Victoria) Cecilia Santiago, Mentor Ashley Skiffington, Professional Practice Leader

Piloting a Falls Risk Reduction Program in the Trauma & Neurosurgery Intensive Care Unit Barbara Ferguson, RN, BScN St. Michael’s Hospital, Toronto, Ontario, Canada FOCUS

PROCESS CHANGES (CONTINUED)

To create and implement a falls prevention program for the Trauma and Neurosurgery Intensive Care Unit (TNICU) based on current literature on falls in the critical care environment, applicable SIMPLE interventions and the RNAO Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult.

STANDARDIZED FALLS PREVENTION PLAN INTERVENTIONS The following components of the standardized falls prevention plans are to be implemented for every patient:

BACKGROUND Every patient in the critical care department is considered a high risk for falls due to the prevalence of confusion, agitation, mobilization against advice; the significant amount of equipment attached to the patient; deconditioning of the patient; and the use of medications such as sedatives, opioids, or antihypertensives. Although every patient is considered a high risk for falls, no formal falls risk reduction policy was in place.

PURPOSE & OBJECTIVES To trial a falls risk reduction program for the Trauma and Neurosurgery Intensive Care Unit.

Strategies for the Management of Pain, Agitation and Delirium

PAD Algorithm utilized.

Bed Positioning

When patient care is not being provided and the family is not present, the bed should placed in the lowest possible position. Brakes are to always be on.

Elimination Pattern Appropriate ICU bowel routine is to be ordered.

Assessment Regular Patient Observation

Appropriate nurse-to-patient ratio based on patient acuity is provided.

Patient and/or Family Education

Patients and/or their families will be informed of the care plan that is implemented to prevent them from falling. They will be encouraged to participate in the falls prevention care plan. The Lexicomp education handouts will be given to all patients and/or their families.

PROCESS CHANGES As every patient is considered a high risk for falls, all patients will have a standardized falls prevention plan.

If, based on clinical judgement of the inter-professional team, a patient is identified as needing a more detailed and personalized falls prevention plan, the inter-professional team will collaborate to develop and implement an individualized falls prevention plan.

If a fall occurs, a debriefing with the inter-professional team should occur during the same shift as the fall using the Critical Care Falls DEBRIEF Tool, pictured to the right.

Critical Care Falls Debrief Tool: Your Guide for a Post-Fall Review 1. DEBRIEF happens after EVERY fall 2. It takes place on the same shift that the fall occurred 3. A DEBRIEF will be attended by all inter-professional staff members involved in the patients care 4. This tool is intended for use in guiding and structuring post-fall debrief team discussions. General documentation requirements are outlined in section 4.0 of this policy.

Was this the patient’s first fall in the hospital?

Description of If no, how many other times has the patient fallen?

Events Who found the patient? Or who was witness to the fall?

What happened?

Brief Review

Interventions in place

Evaluation and Future care

Did the patient have their personal belongings in reach?

Did the patient have any mobility or physical weakness of any kind?

Did they have any impaired cognitive functioning or decreased insight into their physical limitations?

Any other contributing factors? (i.e. medications, elimination, etc.)?

Was Pain, Agitation and Delirium assessed in the last hour and has the PAD Algorithm been in use?

Was the bed in the lowest possible position with breaks on?

Was there an appropriate ICU bowel routine ordered?

Has the patient and/or family been educated on their falls risk?

Was there an active referral to the interprofessional team members (e.g. PT, OT, Pharmacy, etc.)?

Were the surroundings clean, dry, and un-cluttered?

Does the patient have an individualized falls prevention care plan? (If not, one should be developed) Was next of kin notified?

Was an event tracker completed?

How could this fall have been prevented?

What changes will we make in the way we care for this patient?

What additional falls prevention strategies could be utilized to prevent any further falls (e.g. use of bed alarms, scheduled toileting, call bells)?

Has the patient and/or family been re-educated on their fall risk and fall prevention care plan?

What changes will we make in the way we deliver care on our unit?

CONCLUSION

METHOD

Plan Do Study

Act

•Development of Falls Risk Reduction Program with the Critical Care Educators Falls Working Group •Staff Engagement for feedback in developing new policy

•Pre-Education Audits: Observational audits performed on 50 bedsides, looking for the presence or absence of the Standardized and Individualized Falls Prevention Plan interventions •Implementation of policy using: •Education sessions and interactive discussions in small groups at patient bedside with quick reference guide (fig.1) •Educational poster in staff conference room summarizing new policy •Email follow-up

•Post-Education Audits: Observational audits performed on 50 bedsides, looking for the presence or absence of the Standardized and Individualized Falls Prevention Plan interventions •Feedback provided by staff led to a change in process and location of the DEBRIEF tool •Identified gap in knowledge for how to use bed alarms and provided education on the different bed alarms available

•Communication: KARDEX to be modified to include a designated area to write Individualized Falls Prevention Plan •Documentation: ICU Flowsheet has been modified to allow for documentation of Standardized Falls Prevention Plan and assessment for Individualized plan however it is still pending various committee approval for roll-out

Fig.1: Quick Reference Guide (back)

Take a deep breath and follow these steps for post fall management If a patient falls, the following steps will be taken: 

Inter-professional Team Member Involvement

An active referral to inter-professional team members (e.g., PT, OT, Pharmacy, Speech Language Pathology) as appropriate based on patient care needs.

Minimize Clutter

A physical environment (including patient bedsides and the path to the bathroom) that is free of extraneous clutter.

INDIVIDUALIZED FALLS PREVENTION PLAN INTERVENTIONS Examples of individualized falls prevention strategies may include, but are not limited to the following: Bed Alarms Call Bells Mobility Plan

Toileting Schedule

Utilize bed alarms when available.

Utilize call bells when available and patient can participate.

Once it is appropriate to mobilize a patient, ensure a mobility plan has been established, signage displayed

by PT and followed by all staff.

Scheduled toileting once patient has Foley catheter discontinued.

• The pre-education audits helped to quantify the fact that the TNICU had multiple falls prevention interventions already in place even though there was not a formal falls prevention program.

• The creation and implementation of a falls prevention program in the TNICU introduced the use of best practices for staff to guide their efforts in preventing falls.

• Post-education audits showed an increase in use of falls prevention interventions. Most notably, there was an increase beds being in the lowest possible position; however, there is still room for improvement to attain the ultimate goal of all patients with beds in the lowest possible position.

• Staff were able to identify patients who needed an individualized care plan and develop personalized strategies for preventing falls.

• A gap in knowledge for the use of bed alarms was identified, and after education was provided, every patient with an individualized care plan had their bed alarm turned on.

   

Complete a full patient assessment, including assessing for injury, and safely assist patient up from the floor.

Notify the MRP and appropriate consulting services, charge nurse, and Liz (CLM) or delegate.

Notify the patient’s next of kin of the fall. This is to be completed on the same shift that the fall occurred.

Complete an incident report in the St. Michael’s Hospital Event Tracking System, giving as much detailed information as is known.

Using the Critical Care Falls debrief tool as a guide, initiate a debrief session with inter-professional team members. There is no documentation requirement associated with the post-fall debrief00\

POST FALL DOCUMENTATION:  The post-fall assessment  Notification of MRP, relevant consulting services, charge nurse, and Liz (CLM)  Notification of Next of Kin  Post-fall interventions  Occurrence of a debrief  Plan to prevent future falls

FINDINGS: OBSERVATION AUDITS Pre-Education Audits: • Although no formal falls prevention program was in place, staff in the TNICU had informally implemented the majority of the proposed standardized falls prevention strategies.

• There was no standardized way of communicating falls prevention strategies for patients.

• The largest gap in practice was that none of the patient beds were in the lowest possible position.

Post-Education Audits: • Three patients were identified to require an individualized falls prevention plan and every one of these patients had a bed alarm turned on and falls prevention strategies written in the Kardex.

• One of these identified patients was able to use a call bell and it was within reach.

• There was a 34% increase in bed being in lowest possible position when not in use or family not present.

RECOMMENDATIONS/NEXT STEPS • An education refresher on communication and on change in documentation when the new KARDEX and flowsheet are available • Falls Prevention Plan added to the ICU-ICU TOA checklist • Education added to the TNICU orientation • Documentation auditing added to the dashboard

REFERENCES Eagle, D.J., Salama, S., Whitman, D., Evans, L.A., Ho, E. & Olde, J. (1999). Comparison of three instruments in predicting accidental falls in a general teaching hospital. Journal of Gerontological Nursing, 25(7), 40-45.

Halm, M. A., & Quigley, P. A. (2011). Reducing falls and fall-related injuries in acutely and critically ill patients. American Journal of Critical Care, 20 (6), 480-484.

Hauer, K., Lamb, S. E., Jorstad, E. C., Todd, C., & Becker, C. (2006). Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials. Age and Ageing, 35(1), 5-10.

Hodgkinson, B., Lambert, L., Wood, J., & Kowanko, I. (1998). Falls in acute hospitals: a systematic review (Vol. 1). Joanna Briggs Institute for Evidence Based Nursing and Midwifery.

Ireland, S., Lazar, T., Mavrak, C., Morgan, B., Pizzacalla, A., Reis, C. & Fram, N. (2010). Designing a falls prevention strategy that works. Journal of Nursing Care Quality, 25(3), 198-207.

Meyer, G., Kopke, S., Haastert, B. & Muhlhauser, I. (2009). Comparison of a fall risk assessment tool with nurses’ judgment alone: a cluster-randomised controlled trial. Age and Ageing, 38(4), 417-423.

National Patient Safety Agency (2007). Slips, trips and falls in hospital. The Third Report from the Patient Safety Observatory. Retrieved from www.npsa.nhs.uk.

Oliver, D., Daly, F., Martin, F. C., & McMurdo, M. E. (2004). Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age and ageing, 33(2), 122-130.

Registered Nurses Association of Ontario (2005). Revised- Prevention of Falls & Fall Injuries in the Older Adults. Toronto, ON: Registered Nurses Association of Ontario.

Registered Nurses Association of Ontario (2005). Revised- Prevention of Falls & Fall Injuries in the Older Adults. Toronto, ON: Registered Nurses Association of Ontario.

Richardson, A., & Carter, R. (2015). Falls in critical care: a local review to identify incidence and risk. British Association of Critical Care Nurses, doi: 10.1111/nicc.12151. Retrieved January 5 2016.

Society, A. G., Society, G., Of, A. A., & Panel, O. S. (2001). Guideline for the Prevention of Falls in Older Persons. Journal of the American Geriatrics Society, 49(5), 664-672.

Schwendimann, R. (2006). Patient falls: a key issue in patient safety in hospitals (Doctoral dissertation, University_of_Basel).

World Health Organization. (2012, October). Falls. Retrieved from http://www.who.int/mediacentre/factsheets/fs344/en/

ACKNOWLEDGEMENTS The author would like to thank Colleen McNamee, Denise Ouellette, Vasuki Paramalingam, Elizabeth Butorac, the Critical Care Educators Falls Prevention Working Group and the members of the BPG Communities of Practice.

The Family Health Team Nursing Education Initiative: Enhancing Collaborative Patient Care Bethany Kwok, RN, BScN, MN, Daniel Bois, RN, BScN, Newton Leong, RN, BScN, Cheryl Turzanski, RN, BScN, Deborah Langlois, BScN, Med, MBA St. Michael’s Hospital

FOCUS

INTERVENTION/PROCESS

The implementation of a two-year Registered Nurse (RN) Education Strategic Plan to promote the partnerships between nurses, the person, and their families within the context of the Registered Nurses Association of Ontario’s (RNAO) best practice guideline (BPG) on Person and Family-Centred Care (2015).

INTERVENTION: Three educational workshops • Nov, 2015: BETTER Program • Dec, 2015: Well-Baby (Rourke Baby Record) • Jan, 2016: COPD/Smoking Cessation

• One of the four objectives from the Ontario Ministry of Health and Long Term Care’s Patients First: Action Plan for Health Care (2015) is to inform patients by “support[ing] people and patients – providing the education, information and transparency they need to make the right decisions about their health” (p. 5).

• RNAO's BPG on Person-and Family-Centered Care (2015) recommends that an implementation of a nursing education plan on patient empowerment, communication and shared decision-making to improve patient experience and health outcomes.

• A priority from St. Michael’s Hospital Department of Family and Community Medicine (DFCM) Strategic Plan 2015-18 (2015) is to optimize the scope of practice of the registered nurse (RN) to deliver enhanced patient care.

PURPOSE & OBJECTIVES Goal: To enhance the patient’s health care experience and elevate the patient’s ability to make informed health care decisions and goals facilitated by the Family Health Team (FHT) RNs. Objectives: 1. To heighten the FHT nurses’ degree of knowledge and confidence in conducting health promotion and disease prevention activities, i.e. well-baby visits, COPD management, and smoking cessation.

2. To enhance patient experience and patient health outcomes by utilizing standardized evidence-based RN education.

PATIENT FEEDBACK “(Nurse) does a lot of teaching which helps me feel comfortable about nutrition, vaccines, and stages my children going through”.

“Very active discussion around this topic (child development) as our child speaks more than one language”.

PROCESS: 1. Pre / post-education session surveys To elicit the RN’s level of knowledge and confidence after attending the education sessions

CONCLUSION • The RNs self-report an increase in knowledge and confidence in patient health teaching and promotion.

• This is further reflected in the three month follow-up survey with nurses and the caregiver survey post wellbaby visit.

• Practice change is sustained and RNs are doing a more comprehensive well-baby visit.

• The overall result is a more thorough and personalized visit supporting person and family centered care.

2. Three-month Well-Baby follow up nursing survey Nursing survey to evaluate the utilization of the Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance 3. Well-Baby patient survey Patient survey to obtain patient perspective on their wellbaby visit experience with the nurse

RESULTS Pre Post-Education Session Surveys: Percentages of nurses who attended all 3 workshops: 86% (n = 26) Nursing Response: Pre and Post Education Survey Percentage of nurses that reported 8 and above

BACKGROUND

Patient Survey: Post Well-Baby Visit

45

40

Pre-Session 35

Post-Session 30

25

20

In the three-month well-baby follow up nursing survey (n=15): • 87% of nurses reported more confidence conducting well-baby visits • 100% felt they were providing better patient and family care Nutrition • Feed baby every 2-4 hours • Expect 5-6 wet diapers a day Sleep • Counselled against co-sleeping • No pillows, no stuffed animals in crib • Expect baby to sleep 16-18 hours a day; 3-4 hours at a time

15

10

5

0

Well-Baby - Level COPD/Smoking Well-Baby - Level COPD/Smoking of Knowledge Cessation - Level of Confidence Cessation - Level of Knowledge of Confidence

Environmental Health • No sunscreen less than 6 months of age • Discuss third hand smoke exposure

(Rourke, L., Leduc, D., & Rourke, J., 2014)

RECOMMENDATIONS/NEXT STEPS • Continue ongoing RN education initiative and sustain best practices to increase knowledge and confidence levels • Formalize education plan for current and newly hired RNs • Address barriers to care in educational initiatives i.e. cultural and language diversity • Disseminate current findings i.e. local education events

REFERENCES Ministry of Health and Long-Term Care (2015). Patients First: Action Plan for Health Care, Catalogue No. 019729 ISBN No. 978-1-4606- 5165-0, Queen’s Printer for Ontario.

Registered Nurses’ Association of Ontario (RNAO). ( 2015). Person-and-family-centred care.

Toronto, ON: Author.

Rourke, L., Leduc, D., & Rourke, J. (2014). Rourke baby record: Evidence-based infant/child health maintenance. Retrieved from http://www.rourkebabyrecord.ca/pdf/RBR2014_onepage.pdf St. Michael's Hospital, Department of Family and Community Medicine. (2015). St. Michael’s Hospital Academic Family Health Team and Department of Family and Community Medicine Strategic Plan 2015-2018. Retrieved from http://www.stmichaelshospital.com/pdf/corporate/strategic-plan-2015-18.pdf

ACKNOWLEDGEMENTS We thank Professional Practice for their sponsorship in this BPG project, the Clinical Leader Managers for their leadership support, Jean Wilson and Kimberley Gordon for their contribution to the RN Education Initiative, and the FHT RNs for their participations in the evaluation process.

Falls Prevention in the Emergency Department Carolyn Hamill RN, BScN ENC(C) Emergency Department Lee Barratt, RN, MN, ENC(C) Emergency Department Karen Gaunt RN, MHSc, ENC(C) Emergency Department St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS  Improve safety for Emergency Department (ED) patients by highlighting falls risk identification & falls prevention strategies.  Increase awareness and knowledge of current falls risk assessments and prevention strategies utilized in the ED & at St. Michael’s Hospital.  Increase communication of falls risk assessments among the health care team and during transfer of accountability (TOA).  Implement a strategy to document falls risk screening and fall prevention interventions in the ED.

PURPOSE & OBJECTIVES Place the names  Increase the nurse’s knowledge and awareness of factors putting patients at risk for falls.  Implement a falls risk screening and falls prevention strategy in the ED.  Increase documentation of falls risk screening and fall prevention strategies implemented during a patient’s ED visit.  Provide opportunity for patient and family participation in fall prevention plan of care.  Increase communication with the health care team & during TOA patients identified as a falls risk and fall prevention strategies initiated in the ED.

RNAO (2011) Best Practice Guideline Prevention of Falls and Fall Injuries in the Older Adult: 1.0 Assess fall risk on admission.

1.1 Assess fall risk after a fall.

3.0 Nurses include environmental modifications as a component of fall prevention strategies.

BACKGROUND  Most ED patients are at risk for falls due to underlying medical conditions, current illness, altered level of consciousness (LOC), impaired mobility, polypharmacy &/or substance misuse.  The ED is a busy and noisy environment 24 hrs/day which can contribute to increased confusion/delirium in the elderly.  No formal documentation of falls risk screening/assessment and falls prevention strategies in the ED.  Missed opportunities for communication of patients identified as a falls risk and fall prevention strategies implemented in the ED among the health care team and at TOA .

RESULTS  Completed process map of current state of the institutions  Audit at triage validated that most ED patients are at risk for falls.

Those with a history of falls are at higher risk and concern.

 41 staff surveys completed (40%); current knowledge and practices identified, staff ideas/feedback obtained and shared with staff.  Staff have started using falls risk armbands, bedside signs & stickers to flag charts.  Patient self-declaration signs are posted throughout all waiting areas, bathrooms and most treatment areas (where wall space available) in the ED.  Changes to nursing documentation to incorporate falls risk screening questions and fall prevention strategies in progress.

INTERVENTION/PROCESS  Evaluated current practice o Process map (a challenge!) o Surveyed nurses and clinical assistants o Real time observation at triage to audit/validate the ED Falls Risk Criteria categories (LOC, mobility, patient/family perspective, RN assessment/clinical judgement) o Event tracker review of previous falls in the ED  Staff communication via e-mail, posters, meeting in small groups during shift o Staff survey results o Falls risk criteria, fall prevention strategies & falls risk screening questions o Changes to nursing documentation to include falls risk screening and fall prevention strategies, staff ideas & feedback obtained  Implementation of specific falls prevention strategies in the ED o ED patients will be screened for falls risk including: history of falls or fear of falling in the past 3 months, patient &/or family concerns, falls risk criteria & nurse’s clinical judgement o Falls risk criteria & falls prevention interventions/strategies will be posted in ED charting areas as a resource o Falls risk arm bands, bedside signs & stickers to flag charts have been introduced o Patient self-declaration signs visible throughout department o Patient education pamphlets on falls prevention in hospital and at home

CONCLUSION  Staff are talking about falls prevention and using the available tools to identify falls risk and strategies implemented.  Even though most of our patients are at risk for falls, we have learned that there are some indicators that are higher risk than others. Recognizing and communicating this has become the focus of our project with a goal of improving patient safety.

Tools are starting to be used! Staff are engaged and interested in the documentation changes.

RECOMMENDATIONS & NEXT STEPS  Finalize changes to nursing documentation  Finalize/print posters listing Falls Risk Criteria and Falls Risk Prevention Strategies: make visible throughout ED.  Complete staff education: documentation strategy, falls risk screening, assessment and prevention strategies, communication between patient/family, health care team & during TOA, falls response process  Chart audits to assess compliance of falls risk screening & prevention strategies.  Follow up on falls documented in event tracker.  Obtain staff feedback throughout “roll out” using various methods.

REFERENCES • Registered Nurses Association of Ontario (2011). Prevention of Falls and Fall Injuries in the Older Adult.

• Milisen, K., Coussement, J., Flamaing, J., Vlaeyen, E., Schwendimann, R., Dejaeger, E., Surmont, K., & Boonen, S. (2012).

Fall prediction according to nurses clinical judgement, differences between medical, surgical, and geriatric wards. JAGS. 60: 1115-1121 • Quinte Health Care. (2015). Falls prevention patient and family education material • Terell, K., Weaver, C., Giles, B., & Ross, M. (2009). ED Patient Falls and resulting injuries. Journal of Emergency Nursing 35(2) 89-92 • Alexander, D., Kinsley, T. & Waszinki, C. (2013). Journey to a safe environment: Fall prevention in an emergency Department at a Level 1 trauma Centre. Journal of Emergency Nursing 39(4) 346-352 • North Bay Regional Health Centre, (2015). Policy and procedure Falls Management.

• St. Michael`s Hospital. Complete fall risk assessment and SIMPLE tool.

• St. Michael`s Hospital. (2016). Draft critical care department fall risk reduction policy • William Osler Health System (2012). Policy: Falls prevention programAmbulatory Care and Out patient clinics

ACKNOWLEDGEMENTS Jodi Denbok, RN, ED Agnes Dzialo, RN GEM, ED Colleen McNamee, RN, MN, Mentor Nursing Professional Practice Marcelo Silles, Medical Media

Increasing Rates of Woman Abuse Screening in the Obstetrics Department Caroline Laidlaw, RN, BScN, Mary Murphy, RN, MN, Sharon Adams, RN, MN, PNC, Amanda Hignell, RSW, MSW St. Michael’s Hospital

FOCUS

INTERVENTION/PROCESS

In 2010, the use of the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline (BPG) entitled Woman Abuse: Screening, Identification and Initial Response was rolled out in the Obstetrics (OB) Department The overall goal of this initiative is to facilitate performance of woman abuse screening (WAS) in the OB department

PLAN

Create timeline

Consult staff previously involved

Identify knowledge gaps

CONCLUSION

RESULTS: SURVEY n=8 (All Labour and Delivery RNs)

• Feedback from staff indicate that a knowledge gap is being filled

Question: Which of the following do you feel are barriers to WAS?

• Chart audits post-intervention are ongoing, and will determine: changes in WAS rates, and quality of documentation related to WAS

Consult staff in antenatal clinics

RECOMMENDATIONS/NEXT STEPS • Implement a change readiness survey for staff, as change fatigue is a proposed reason for some challenge in implementing intervention

BACKGROUND

• Develop a formal ToA tool, in which WAS is included

• 2009 GSS: 6% of Canadian women in a spousal relationship experienced spousal violence in the past five years (Measuring violence against women: Statistical trends, 2013) • 40% of abused women in Canada say they were first assaulted during pregnancy (Statistics Canada, 1999)

DO Informal interviews with staff

Distribute surveys

• Conduct ongoing one-on-one or small group sessions with staff One-on-one teaching

Unit resources (posters, binders)

• High risks exist to woman and fetus when abuse is present during pregnancy (Henderson, S., & Cosgrove, K., 2009)

• Implement a staff post-intervention survey

RESULTS: INFORMAL INTERVIEWS

• Establish a sustainability working group (RNs from OB/GYN)

n=12 (Labour and Delivery and Post-Partum RNs)

• Develop and implement a formal hospital-wide woman abuse screening policy

• In 2011, close to 80% of inpatients were screened for abuse on the OB floor

STUDY • In the Fall of 2015, only 1.1% of inpatients were screened for abuse on the OB floor • Antenatally, women are only screened for abuse during their initial clinic visit

Patients may be annoyed when asked multiple times

Conduct random chart audits to determine presence of change in screening rates

REFERENCES •

Relationship with RN is too brief in L&D to ask

• To increase rates of woman abuse screening in the OB department

• To facilitate a culture that promotes safety, and in which abuse is not acceptable

Pace is too fast in L&D to ask

• Arrange a staff education day partly dedicated to WAS training and sensitivity

•

PURPOSE & OBJECTIVES

• To improve documentation of woman abuse screening

Fear of offending patients with personal questions

ACT Form working group to foster ongoing uptake of intervention

Engage team leaders for help in giving all patients five minutes alone with RN for “safety assessment”

Perception that patients won’t disclose in L&D

Reported Feelings about Woman Abuse Screening in L&D

Inappropriate place to screen patients

Requesting a script

• •

All patients should be screened

Figure 1. Main themes from informal interviews with staff

Henderson, S., & Cosgrove, K. (2009). What health care workers need to know about gender-based violence: An overview. Retrieved from www.gbv.scot.nhs.uk Lutz, K.F. (2003). Abused pregnant women’s interactions with health care providers during the childbearing year. Journal of Obstetric, Gyencologic & Neonatal Nursing, 34, 2, 151-162.

Measuring violence against women: Statistical trends. (2013). Canadian centre for justice statistics. Retrieved from http://www.statcan.gc.ca/pub/85-002x/2013001/article/11766-eng.pdf Registered Nurses Association of Ontario (2012). Woman Abuse: Screening, Identification and Initial Response. Toronto, Canada: Registered Nurses Association of Ontario, retrieved from rnao.org/bestpractices

ACKNOWLEDGEMENTS This project was facilitated by Professional Practice. Particular thanks to Ashley Skiffington. This initiative is supported by the ongoing work of the RNs in the OB/GYN program, as well as Mary Murphy, Sharon Adams and Amanda Hignell.

Nurse-led Initiative to Improve Patient’s Experience with Expected Date of Discharge Cristina Cetin, RN; Grace Fryfogel, RN; Norine Meleca RN, MN, MScHQ; Natalee Elvie, RN, BN, MScN St. Michael’s Hospital

FOCUS • This initiative is focused on patient centered approach to improve transfer of accountability (TOA) and expected date of discharge with the Cardiology team on 7CCS • It is in alignment with the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline (BPG) on Professionalism in Nursing and Establishing Therapeutic Relationship

BACKGROUND

PROCESS

RESULTS: Education

II. Education of Staff

• 85% (n=27) RNs received education about the EDD process and about involving patients & families on EDD discussion

RESULTS: Compliance Audits

1. Communication about patient’s EDD: • Discharge board at nursing station • Work list on Soarian • MD notes/orders • Charge nurse bullet round reports • Kardex 2. How to Engage Patients About EDD: • During shift-to-shift ToA • Throughout the shift

2015

2016

• St. Michael’s Hospital (SMH) standard early discharge initiative was introduced in 7CCS

• Expected date of discharge (EDD) was first introduced on 7CCS during staff meetings, group emails & bullet rounds

• BPG sustainability initiative focuses on engagement of patients & families in the discharge planning process

PURPOSE • To raise an awareness among staff on 7CCS about the need to include the patients and families in EDD discussions.

III. Audits 1. Real-time Audits of Compliance to EDD Process 2. Asked patients about whether they are aware of their EDD or not on audit days

RESULTS: Patient and Family Interview (n=10) “Board is good because we can also write notes on board for questions.”

“The whiteboard is a good idea because it keeps you informed.”

“I noticed the whiteboard. It is a good idea because at least I know the day of my discharge.”

Interview questions: 1. Are you aware of your date of discharge?

2. Have you noticed the white board( with EDD information) in your room?

3. Are the nurses including you in the discussion about your date of discharge?

4. How do you get information about your date of discharge?

RESULTS: Compliance Audits Health Care Team % aware

Board Updated %

100.00%

90.00%

Target = 75% 80.00%

70.00%

60.00%

50.00%

40.00%

PROCESS Interview of Patients and Families

Figure 1: BPG Champions Cristina Cetin & Grace Fryfogel examining the EDD Board

Stamp on Kardex %

• To examine each components of the EDD process and create strategies in increasing patients and families’ awareness about their EDD.

I.

DISCUSSION/CONCLUSION

“I like it because the name of my nurse/ helper and MDs were all written. I can tell my daughter.”

30.00%

“The whiteboard is good only if it’s updated.”

“The eraser should be moved because it blocks the doctor’s name.”

20.00%

10.00%

• Patient feedback indicates that they like the whiteboards and find the information displayed helpful.

• In the initial rollout of the EDD in 7CCS, involving patients in the EDD discussion was not included in their education. As part of the BPG sustainability efforts, the champions provided education to the majority of RNs. Education involved reinforcement about updating the whiteboard and Kardex. New process of engaging patients and families about their EDD during ToA and throughout the shift was induced.

• Post education audits show that staff compliance to the EDD process is above target of 75%.

• The proportion of patients who were aware of their EDD on audit dates are above the target of 85%.

• Challenges: • Keeping the whiteboard current when moving patients from room to room with no patient identifier (e.g., isolation) • Casual or agency staff unaware of the new process • Unable to update in a timely manner when markers dry or missing • Next Steps: • Include N.P./Resident on patient’s whiteboard • Conduct more audits to evaluate sustainability • Recruit more staff champions to keep the momentum • CLM to provide ongoing reminders to staff to update whiteboard

0.00% 16-Dec 17-Dec 18-Dec 19-Dec 20-Dec 21-Dec 22-Dec 23-Dec 24-Dec 25-Dec 26-Dec 27-Dec 28-Dec 29-Dec 30-Dec 31-Dec 1-Jan 2-Jan 3-Jan 4-Jan 5-Jan 6-Jan 7-Jan 8-Jan 9-Jan 10-Jan 11-Jan 12-Jan 13-Jan 14-Jan 15-Jan 16-Jan 17-Jan 18-Jan

2014

Figure 3: Proportion of patients who were aware of their EDD on audit dates

Figure 2: Staff compliance to EDD workflow process

ACKNOWLEDGEMENTS

• Nursing Practice and Education for funding to support this initiative • Cecilia Santiago (Mentor), Ashley Skiffington, Marta Sliz, Ada Andrade

Empowerment through Knowledge Irene Pryshlak RN, Patricia Noe RN, Christopher Bari BScN3 St. Michael’s Hospital

DEMOGRAPHICS

FOCUS

• Increase awareness of patient and family library • Provide patients with internet sites related to their condition • Patient information booklets and pamphlets provided in waiting areas • Conduct a survey post-appointment and compare data obtained to current findings • Survey questionnaire to be revised; propose multiple answer options as opposed to short answer • Identify patient as new or follow-up as learning needs will differ

Engage and empower patients by assessing their informational/educational needs

BACKGROUND What • Patient have poor understanding of their health condition, next steps of care that will be required, and treatment options.

Why • Knowledge is empowerment • Decreases anxiety, increases patient control • Patients will have an opportunity to actively participate in the decision making process and disease management • Patient safety and quality of care will improve • Patient satisfaction will increase • This work aligns with recommendations from the “Client Centered Care” Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline

PURPOSE & OBJECTIVES To provide patients with customized, tailored, and patient centered information/education.

Information obtained from needs survey indicating: • Demographic data • Level of health literacy • What patients want to know about their condition • How their condition affects their daily living • Where and how they obtain their health information

INTERVENTION/PROCESS Patients information needs assessment surveys were conducted with patients from four different clinics: • General Surgery • Colorectal Surgery • Gastroenterology • Hematology Prior to seeing their physician, patients surveys were conducted.

Patients were handed the survey on a clipboard and were asked voluntarily to complete the questionnaire previously developed by the 4CC nursing staff to identify patient informational needs.

LIMITATIONS

RESULTS

CONCLUSION

• Survey questions are generally broad and open ended • Question 4 and 6 are commonly misunderstood and poorly answered • Limited sample sizes; each of the clinics involved less than 25 patients • Some physicians did not agree with the survey questions and were reluctant for their patients to participate

REFERENCES Patients from all clinics want to understand: • Causes of their condition and disease process • Treatment options; ways to improve, maintain, and manage their condition • Next steps of care • Pain control Patients also stated concerns for: • Activities of daily living • Mobility • Housekeeping • Meals • Self care • Rest and Sleep • Most patients rely on healthcare providers and the internet to obtain information.

• Most patients were not aware of the St. Michael’s Patient and Family Learning Center.

Steps taken to evaluate current educational sources: • Inventory of existing counseling and patient educational material was conducted.

• Physicians currently address patients diagnosis, causes, treatment options, plan follow-up appointments, and provide written information during consultation.

Coulter, A. (2012). Leadership for patient engagement. The Kings Fund. Retrieved from http://www.kingsfund.org.uk/sites/files/kf/leadership-patient-engagementangela-coulter-leadership-review2012-paper.pdf Kanj, M. & Mitic, W. (2009). Promoting Health and Development: closing the implementation gap. World Health Organization. Retrieved from http://www.who.int/healthpromotion/conferences/7gchp/Track1_Inner.pdf Lubetkin, E., Lu, W. & Gold, M. (2010). Levels and correlates of patient activation in health center settings: building strategies for improving health outcomes. Journal of Health Care for the Poor and Underserved, 21(3). Retrieved from http://search.proquest.com.ezproxy.lib.ryerson.ca/nursing/docview/746780525/3163A 3444C7C4E17PQ/13?accountid=13631 Wingard, R. (2005). Patient Education and the Nursing Process: Meeting the Patient’s Needs. Nephrology Nursing Journal, 32(2). Retrieved from http://search.proquest.com.ezproxy.lib.ryerson.ca/nursing/docview/216545030/C0E0E 88CB2B94F6FPQ/4?accountid=13631

ACKNOWLEDGEMENTS Contact Information: 4CC Specialty Clinics – Anna Kacikanis Clinical Leader Manager

TRANSFER OF ACCOUNTABILITY For Break Coverage/ Out of Office/ Home Visits & Vacation in the Home Dialysis Unit Jumi Charles, RN, BScN, CNeph(c) St. Michael’s Hospital, Toronto, Ontario, Canada FOCUS

PURPOSE & OBJECTIVES

Transfer of accountability (TOA) for break coverage, out of office, home visits and vacation within the home dialysis unit.

Purpose: To standardize a transfer of accountability in the home dialysis unit; to improve communication, decrease obscurity of responsibilities, reduce patient anxiety and overall improve patient and staff experience and satisfaction.

This RNAO BPG project aligns with Accreditation Canada Required Organizational Practice on care transitions: • use effective communication to share client information • educate the client, their family and caregivers • use standardized documentation tools and communication strategies • evaluate the effectiveness of transition planning on the continuity of care.

Transfer of Accountability- “involves the transfer of rights, duties, and obligations from one person or group of people to another” (Solet et al., 2005).

“Communications at the time of handover should result in a clear understanding by each provider about who is responsible for which aspects of the client’s care”(American College of Obstetrics and Gynaecology, 2007). “While providers may think they perform handovers well, the evidence suggests major gaps in care occur during these critical exchanges” (Tregunno 2009).

Place the names of the INTERVENTION/PROCESS institutions (Continued)

Objectives: 1. Documented less overtime due to loss of lunch break 2. Nurses to get breaks in a timely fashion 3. Specified assigned accountability on daily assignment 4. Clinical documentation compliance of the use of the TOA form (while on vacation).

INTERVENTION/PROCESS A nine question survey was filled out by 7/7 staff members; 6 nurses, 1 clerical in the home dialysis office. Questionnaire was developed to get feedback on current processes re: coverage.

A buddy system was created for vacations, out of office and home visits

BACKGROUND

A transfer of accountability reminders form was created

Home dialysis Buddy System for Coverage of: Vacations, Out of Office and Home Visits

Transfer of Accountability in Home Dialysis Unit- February 2016

February 2016

The home dialysis unit comprises of: • 1 manager, 2 nephrologists, 6 nurses,1 case manager, 1 nurse navigator, 1 full-time clerical, 1 pharmacist, 1 dietician and 1 social worker • We train patients on how to do dialysis at home.

-Currently 104 peritoneal dialysis (PD)patients; 23 hemodialysis (HD)patients • Nurses do home visits 1st day at home, 6 weeks, 6 months, annually and as needed.

Ramona

Anita

Jumi

Oliver

Shaniel

1. Please give report to nurse whom will be there upon your return. i.e if Nurse A is going on break at 12pm please try to give report to Nurse B going at 1pm not 1230pm.

2. For patients in the unit please give report in front of patient.

3. Please inform nurse of expected patients.

4. Ensure break times are on assignment so that other staff will have an idea of where you are.

Back up buddy system i.e away same time or to Split PD/HD Disclaimer: Adjustments may have to be made based on staffing.

Ramona

Home Dialysis Transfer of Accountability (TOA) for Vacation Shaniel

Mary Beth Oliver

Ramona

Oliver Jumi

Ramona Anita

Shaniel

Mary Beth

Mary Beth Shaniel

Jumi Oliver

Jumi

Primary Nurse: Patient 1 Patient A 2 Patient B 3 Patient C 4 Patient D 5 Patient E

Date: Access PD PD PD PD PD

Issue

Follow up required

FINDINGS

Anita

1. Please fill out primary patient list form created by Fatima which can be found on the K+ drive titled “TOA for Vacations Report Form”. If there are no issues please state no issues.

2. Please ensure your buddy is aware of the dates you will be away before your vacation starts and give a verbal report.

3. Please change voicemail and set up email notifications. Please include dates away/returning, nurse covering and how they can be reached (phone number and extension).

4. Please send TOA for Vacations Report Form to the home dialysis team.

Home Dialysis Transfer of Accountability (TOA) for Home Visits/ Out of Office

•The plans set in place are a good start for improving transfer of accountability (TOA) in the home dialysis unit. We are still trialing the processes created.

•All staff are keen on improving the quality of TOA. This will be important to sustain this project.

•It is expected that communication amongst staff for coverage will be clear.

•It is expected that patients know where their primary nurse is i.e break, vacation, out of office.

•It is expected that there is a decrease in nurse’s missing lunch breaks.

Some pre-implementation survey questions & responses: Is a detailed clear report given to designated staff for break coverage?

“Undefined, inconsistent process”

How would you feel giving report to designated staff in front of patients about the specific patient only?

“This can work. It gets the patient involved, can also reduce the chance of minor details being missed”

RECOMMENDATIONS/NEXT STEPS •Feedback from pre & post survey results from CLM and staff •Presentation to home dialysis team on the project •Audit form to be created •Plan to sustain by discussing at staff meetings- quarterly

REFERENCES

Is it clear who is covering staff that are out of office, on home visits and/or vacation?

“Unclear”

Tregunno. D., (2009). Transferring Clients Safely: Know Your Client and Know Your Team. College of Nurses of OntarioTransfer of Accountability Knowledge Translation Project Report.

How would you feel about having a designated buddy system for home visits, out of office and vacations?

“I think it would be ok, however what happens if you and your buddy are away?

Registered Nurses' Association of Ontario [RNAO]. (2014).

Care Transitions. Toronto, Canada: Registered Nurses’ Association of Ontario

Home Dialysis Transfer of Accountability (TOA) for Breaks

Mary Beth

Anita

A TOA for vacations form was created to include issues and follow up required; Specific to each nurse’s primary patient list.

CONCLUSION

Staff feelings towards the new processes:

ACKNOWLEDGEMENTS

1. Please ensure home visits/out of office is on the assignment. Include where you are going and time. Please include if you are returning.

2. If you are not returning please change voicemail and set up out of office email notification.

3. Ensure report is given to buddy.

Coverage for Sick Calls 1. It will be the responsibility of the primary buddy to check and/or change voicemail for colleague.

If primary buddy is away it will be the back-up buddy’s responsibility.

2. Sick and on call nurse: Please call in or email team with pages if possible.

Thank you to the Professional Practice Team and The Home Dialysis Team. at St. Michael’s Hospital.

TOA at Transition: Shift-to-Shift in the CVICU Glen, Janice RN; Harrington, Alana HBSc, MSc, PhD/Dip (ABD); Lewis, Ellen RN. St. Michael’s Hospital

DEVELOPING A SHIFT-TO-SHIFT TOA:

BACKGROUND: • There is no standardized TOA for transitions at shift change

2014

• Nearly 70% of sentinel events are caused by a breakdown of communication (Joint Commission on Accreditation of Healthcare Organizations, 2003)

• One of the things that are often missing is the absence of a common structure for TOA that standardizes the information that is handed over (Yee, et al., 2009, Bensen, 2007, Scovell 2010)

• Several steps were done to develop the shift-to-shift TOA tool • Chart audits were done to identify current practice • Over 100 shift-to-shift reports were audited: • A random selection of patients were for the 2015 calendar year • Charts were reviewed for documentation and notation of handover • Common themes:

ROLLING OUT TOA & SPOT AUDITS: • Options given to staff about the way they wanted to TOA incorporated into our documentation (we have had success with checklist tools and this was the preferred method) • Sticker on the flowsheet

CONCLUSIONS & NEXT STEPS: • Data collection is ongoing • 3-Month trial period will be completed at the end of March • Completion of flowsheet audits to look at compliance • Survey of staff to determine usability, satisfaction and any suggestions for improvement • After trial period TOA will be finalized and incorporated into flowsheet permanently

• Periodic audits to ensure that the tool is being used

• Report given and report received were common phrases documented • Inconsistent or lack of any content of discussion • Very little detail about what was communicated • Variability in where the information was recorded

• Champions to promote the use of the TOA sticker

• Not only a transfer of information but also responsibility and accountability for patient care (Yee, et al., 2009, Alavarado, et al 2006)

• It helps plan, identify safety concerns and aids in continuity of information (Alavarado, et al., 2006) Figure 2: Process flow for TOA development

Figure 4: Final TOA tool for shift-to-shift report

PURPOSE, OBJECTIVE & METHODS: Purpose: • To develop strategies to improve TOA and the consistency of patient care during shift-to-shift transition Objective: • Develop a tool that aids in standardizing and providing structure to the verbal handover between ICU RNs at change of shift Methods: • Chart reviews were performed to determine current documentation practices • Management, medical and frontline nursing staff determined the content that needed to be included in the tool • A variety of tools were proposed to the frontline nursing staff through informal interviews

364 SPOT AUDITS: Figure 1: Documentation patterns from chart audits

• Discussions with our medical team, manager and nursing staff to determine what prompts were important for TOA

• Head to toe was assumed (legend created to demonstrate what a head to toe included; safety checks, alarm parameters etc.)

• Also wanted to prompt discussion about checklists (Braden, SAS Pain, Delirium etc.)

• Ensuring that electronic orders were validated and transferred to the kardex when necessary • Providing a reminder about narcotic disposal and a method for documentation that they were disposed (Accreditation standard)

ACKNOWLEDGEMENTS: • Ashley Skiffington & the Professional Practice Department from St. Michael’s • All the CVICU RNs and the ICU CLM, Medical Director and NP

REFERENCES: Alvardo, K. Et al., (2006). Transfer of accountability: Transforming shift handover to enhance patient safety. Healthcare Quartely, 9, 75-59.

Benson, E., Et al. (2007). Improving nursing shift-to-shift report. Journal of Nursing Care Quality, 22, 8084.

Petersen, L. A., Brennan, T. A., O’Neil, A. C., Cook, E. F., & Lee, T. H. (1994). Does house staff discontinuity of care increase the risk for preventable adverse events? Annals of Internal Medicine, 121, 866-872. doi:10.7326/0003-4819-121-11-199412010-00008 Riesenberg, L.A., Leitzsch, J., & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110, 24-34.

Registered Nurses' Association of Ontario (RNAO). (2014). Care Transitions. Toronto, ON: Registered Nurses’ Association of Ontario

Figure 3: Percent compliance of TOA tool based on spot audits.

Scovell, S. (2010). Role of the nurse-to-nurse handover in patient care. Nursing Standard, 24, 35-39.

Yee, K. C., Wong, M. C., & Turner, P. (2009). “Hand me an ISOBAR”: A pilot study of an evidence based approach to improving shift-to-shift clinical handover. Medical Journal of Australia, 190, S121-124.

Transfer of Accountability (TOA) at Transition: ICU-to-ICU Maria Aquino, RN, BScN, CCN; Janice Glen, RN, Jennifer Hodder, RN, BScN, BN, CCN; & Halley Velasco, RN, BScN, CCN With CLMs: Butorac, Elizabeth RN, MN; Meleca, Norine RN, BScN, MN; & Wannamaker, Karen RN, BScN. St. Michael’s Hospital, Critical Care

BACKGROUND:

CURRENT PRACTICE & DEVELOPING A TOOL:

• There is no standardized TOA for transitions at shift change

• CHART AUDITS: • Over 200 transitions were audited across all critical care units • Only transitions where a patient was moved from one ICU to another were included • Common themes:

2014

•

• Nearly 70% of sentinel events are caused by a breakdown of communication (Joint Commission on Accreditation of Healthcare Organizations, 2003).

• One of the things that are often missing is the absence of a common structure for TOA that standardizes the information that is handed over (Yee, et al., 2009, Bensen, 2007, Scovell 2010)

• Not only a transfer of information but also responsibility and accountability for patient care (Yee, et al., 2009, Alavarado, et al 2006)

• It helps plan, identify safety concerns and aids in continuity of information (Alavarado, et al., 2006).

• • •

ROLLING OUT THE TOA:

Report given and report received were common phrases documented inconsistent or lack of any documentation Very little detail about what was communicated Variability in where the information was recorded

• PRE-SURVEY: • Developed a pre-survey to identify issues that are part of the current practiceand measure satisfaction with transfer experience prior to development of tool • Provided a mock up of a TOA tool to gain feed back • Used the data to revise the tool • 166 Critical Care RNs were interviewed (Approx. 70% of FT/PT ICU RNS) • • •

CONCLUSIONS & NEXT STEPS: • Post-survey data collection is ongoing • Data collection is from frontline nurses who use the tool during ICU-to-ICU transitions • After 6-months charge nurses will be surveyed to determine their satisfaction with the tools

31.9 % were charge nurses 53.0% had TRANSFERRED a patient 59.0% had RECEIVED a patient

• Data collection will be used to determine nursing satisfaction and to refine the tool (if needed)

PURPOSE, OBJECTIVE & METHODS: Purpose: • To develop strategies to improve TOA and the consistency of patient care during transition from one ICU to another.

• Periodic audits to ensure that the tool is being used • Champions to promote the use of the TOA sticker

ACKNOWLEDGEMENTS: •

Objective: • To develop a standardized communication tool used to prompt topics for discussion on transfer Methods: • Chart reviews were performed to determine current practice and documentation for critical care transition points • Critical care nursing staff were surveyed to determine their practices and satisfaction for these types of transfers • A draft of a proposed tool was presented with a presurvey to gain nursing input prior to rolling out the tool

• Majority of experiences were positive but room to improve: •

•

24.5% of all nurses who received a patient were neutral or dissatisfied with receiving a transfer and 20.4% were neutral or dissatisfied when transferring a patient Charge nurses reported higher levels of dissatisfaction • 26.4% of all charge nurses who received a patient were neutral or dissatisfied and 31.3% were neutral or dissatisfied when transferring a patient.

• Critical Care TOA Checklist Sticker made available Feb 2016 •

Surveys about experience and suggestions for improvement completed when sticker used

• •

Ashley Skiffington & the Professional Practice Department from St. Michael’s Alana Harrington from CVICU & Orla Smith from MSICU All the ICU RNs and ICU CLMs

REFERENCES: Alvardo, K. Et al., (2006). Transfer of accountability: Transforming shift handover to enhance patient safety. Healthcare Quartely, 9, 75-59.

Benson, E., Et al. (2007). Improving nursing shift-to-shift report. Journal of Nursing Care Quality, 22, 80(4).

Petersen, L. A., Brennan, T. A., O’Neil, A. C., Cook, E. F., & Lee, T. H. (1994). Does house staff discontinuity of care increase the risk for preventable adverse events? Annals of Internal Medicine, 121, 866-872. doi:10.7326/0003-4819-121-11199412010-00008 Riesenberg, L.A., Leitzsch, J., & Cunningham, J. M. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110, 24-34.

Registered Nurses' Association of Ontario [RNAO]. (2014). Care Transitions. Toronto, Canada: Registered Nurses’ Association of Ontario Scovell, S. (2010). Role of the nurse-to-nurse handover in patient care. Nursing Standard, 24, 35-39.

Yee, K. C., Wong, M. C., & Turner, P. (2009). “Hand me an ISOBAR”: A pilot study of an evidence based approach to improving shift-to-shift clinical handover. Medical Journal of Australia, 190, S121-124.

Facilitating Interprofessional Communication Through the Patient Care Plan Kathryn Hanson BA BScN RN, Tracey Sabaybay, BScN RN, Sean Thomas RN, Smitha Casper-DeSouza RN, Merle Uglow RN St. Michael’s Hospital, Toronto, Ontario

Patient care information not consistently recorded in or reported from PCP

•

PCP primarily a Nursing tool

•

Inter-professional patient care plans with up-to-date information outlining all goals of care promote efficient, safe, and comprehensive delivery of care (Langford et al., 2010; RNAO, 2013)

•

A unit specific nursing staff survey collected in 2014 suggested: a) 53% of respondents moderately satisfied with current PCP tool b) “too much writing” and no “clear space for information” as a dislike of the PCP tool.

•Identify key areas of focus for the tool •Conduct pre-pilot audit of the current PCP tool •Conduct allied health stakeholder survey •Plan awareness campaign •Create project timeline

• Multimodal awareness campaign • Create and implement pilot care plan

• Four sections selected as focus of the audits: Safety, Discharge, Hygiene, Mobility • Audits results based on qualitative and quantitative data • 2 post pilot PCP tool implementation audits conducted:

• Conduct pilot care plan audits • Provide feedback to stakeholders on pilot audit results • Stakeholder survey post care plan implementation

Improve compliance with utilization and documentation of the PCP tool by all members of the inter-professional team

May be related to the perceived ease of use and perceived usability in practice.

•

Nurses remain key gatekeepers

AUDIT 2

•

Paper communication tool proves a challenge to accessing and sharing information

DISCHARGE AND HYGIENE INFORMATION PRESENT

•

Having a multimodal means of communication during the awareness campaign increased visibility of, interest in, and participation in the initiative

BEHAVIOUR

40

FALLS RISK

20

AUDIT 1

80 TURNING TRANSFER

80 60

DISCHARGE HYGIENE

40

RECOMMENDATIONS/NEXT STEPS

20

•

Inform stakeholders of audit and survey results

•

Hold focus groups to assess quality of information and to devise strategies on promoting compliance

•

Continue to encourage compliance with all members of the inter-professional team

•

Conducted feedback survey to assess nursing stakeholders’ overall experience and satisfaction towards PCP tool

Audit PCP tool 6 months post implementation to create final tool

•

Evaluate PCP tool every 5 years or when indicated

•

62.5% satisfied and 29.17% extremely satisfied with the pilot care plans

•

•

According to Allied Health stakeholder survey PCPs ranked 7 out of 8 as resource for patient care information and 67% very open, 34% open to interprofessional PCP

Integrate other corporate initiatives into the use of the PCP tool such as:

40

AMBULATION 0

AIDS

20

PRE

AUDIT 1

AUDIT 1

AUDIT 2

Figures 2-4: Incidence of information found in PCP tool audits between week 1-4 of PCP pilot

AUDIT 2

RESULTS: Stakeholder feedback •

Objectives • Implement communication tool that promotes continuity and efficiency of care and is relevant to Inpatient Mobility •

•

COMMUNICATION

100

MOBILITY INFORMATION PRESENT

PRE

Report >80% satisfaction among stakeholders

Target of >80% overall satisfaction is successfully reached

60

PRE

0

Purpose To enhance and promote interprofessional communication and collaboration through the revision and implementation of a PCP tool.

•

80

0

100

60

The increase of patient information present in key focus areas indicate that there is more information being communicated in the PCP tool

SAFETY INFORMATION PRESENT

• Audit 2 – week 4 of pilot (n=63) • Analyzed and integrated pre pilot stakeholder feedback • Implemented integrated PCP tool • Audited and analyzed key focus areas on week 1 and 4

• 100

• Audit 1 – week 1 of pilot (n=40)

PURPOSE & OBJECTIVES

•

CONCLUSION % OF INCIDENCE

•

Unit using generic Patient Care Plan (PCP) tool, last updated in 2002

RESULTS: PCP tool audits

% OF INCIDENCE

•

INTERVENTION/PROCESS

% OF INCIDENCE

BACKGROUND

b) EDD •

Strongly Agree Agree Neutral

I find it easier to update the pilot care plan than the previous care plan

Disagree

I use the pilot care plan as reference more than the previous care plan

0

10

20 30 % of Total Responses

40

50

Figure 5 - Perceived ease of use and functionality of PCP tool I like that it feels as though information has more of a ‘place’ …it feels more comprehensive because it speaks to ADLs

Very organized, easier to find information because the categories make more sense

Explore electronic PCP tool

REFERENCES Langford, L. K., Tinker, A., & Martial, M. A. (2010). A new life for the care plan? Nursing Management, 41(12), 22-24.

Registered Nurses Association of Ontario. (2013).

Developing and sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes.

Retrieved from http://rnao.ca/sites/rnaoca/files/DevelopingAndSustainingBPG.pdf

Strongly disagree

Format easier to fill out with tick boxes, important safety information easily accessed

a) Nurse to nurse TOA

Encourage everyone to update often!

Figures 1 – PCP tool Figure 6 – Examples of written feedback from nursing stakeholder survey conducted

ACKNOWLEDGEMENTS It’s too early to tell, I’m still adjusting

Thank you to St. Michael’s Hospital and the Community of Practice for the educational and practical support.

Thank you to the amazing staff of Inpatient Mobility on 4B and 9CS, for their support and willingness to engage.

Thank you to our CLMs, Valerie Audette and Smitha Casper-DeSouza for supporting us in this project.

Transfer of Accountability between PACU and 16CC: Developing a standardized approach K. Macqueen, RN, BN, CNCC(C), PANC(C); K. Mansfield, RN, BScN, MN, CGN; N. Rudyk, RN, BScN, MN St Michael’s Hospital, Toronto, Ontario, Canada

BACKGROUND

PROCESS (CONTINUED)

CHALLENGES

• The RNAO’s Best Practice Guidelines on Care Transitions states that discussion and documentation should be standardized and streamlined to ensure clear and accurate transfer of information (RNAO 2014).

• Accreditation Canada’s Standards for Perioperative Services (2015) includes the need for documentation tools and communication strategies that allow for standardized transfer of information during care transitions. This is defined as any time a client experiences a change in team member, location, admission, handover, transfer and discharge.

• There is currently no standardized handover tool between PACU and the surgical floors. Report is given via telephone.

• The goal was to develop a standardized tool that if piloted successfully may eventually be able to be used between PACU and all surgical units.

• A literature review conducted found information related to transfer of accountability (ToA) from OR to PACU, shift to shift, ICU to floor, ICU to ICU and hospital to hospital, but no information regarding ToA from PACU to floor.

• Tool went through 2 revisions before final roll out.

• Roll out began in February

• There had been difficulties giving report due to break coverage, RN workload and assignment, the hope is that with this tool any nurse on 16CC can receive report on a patient, therefore improving patient flow and timely discharge from PACU. • Before roll out there were inconsistencies and discrepancies when giving report due to lack of standardized tool. Certain information was not being communicated or was communicated but not documented.

• Initial resistance to using tool but frequent prompting and reminders ensured compliance

Fig. 1: one initial draft of tool

Fig. 2: final version of tool

CONCLUSION AND NEXT STEPS

FINDINGS

REFERENCES

• The CNO’s practice standards on documentation state that nurses should be minimizing duplication of information in the health record (CNO 2008).

• Feedback from PACU nursing staff was that this tool required frequent “double charting”. Agree that standardized tool is useful but feel there could be a more efficient way.

• Post surveys are still to be completed by both units.

• College of Nurses of Ontario, (2008). Practice Standards: Documentation. Retrieved from: http://www.cno.org/globalassets/docs/prac/41001_documentati on.pdf • Registered Nurses’ Association of Ontario, (2014). Clinical Best Practice Guidelines: Care Transitions. Retrieved from: http://rnao.ca/sites/rnao-ca/files/Care_Transitions_BPG.pdf • Accreditation Canada, (2015). Standards: Perioperative Services and Invasive Procedures. Retrieved from: http://callaway/web-assets/resources/accreditation/standardsperiopertive-services-invasive-procedures.pdf

Some feedback from PACU nurses:

OBJECTIVES • To describe steps undertaken by PACU and 16CC to develop and pilot a standardized tool for ToA. • To describe findings and next steps.

Fig. 3: previous process of giving report

PACU RN signs patient flow sheet once patient meets discharge criteria

Telephone report given to receiving RN on 16CC

Patient discharged to 16CC

“Feel like it is more time consuming.”

PROCESS • Process involved collaboration between PACU, 16CC and the hospital’s ToA subcommitee.

• Education sessions were provided by 16CC Clinical Nurse Educator and PACU CLM to staff on both units prior to roll out regarding the need for standardized ToA • A template was designed, and necessary revisions made before rolling out. Staff were asked for feedback on what should be included and what was not required.

Fig. 4: process of giving report with new tool PACU RN completes and signs tool attached to front of patient chart when ready for discharge

Receiving RN on 16CC completes and signs same tool whilst receiving telephone report from PACU

Information not covered in tool can then be discussed over the telephone before patient leaves PACU

• Everyone in agreement that standardized tool is necessary, however there could be a more efficient tool developed.

• Post surveys to get RN feedback.

• Complete an audit of PACU delays related to giving report to examine whether this has decreased since roll out.

• Complete an audit of event trackers related to handover to examine if there has been an improvement • Plan is to possibly pilot another model similar to those used between ED and TNICU, or the IPASS model used by other units.

“Oh no, MORE paperwork!”

“A lot of double charting.”

Patient and Family Satisfaction Survey: Cardiac Investigation Unit (CIU) Kamala Persad-Ford, RN, MSN, CCN, CCN(C) & Sally Lee, RN, BScN St. Michael’s Hospital FOCUS • To develop, disseminate & analyze a new patient & family satisfaction survey in the Cardiac Investigation Unit (CIU)

• This initiative aligns with recommendations from the following Registered Nurses’ Association of Ontario (RNAO) Best Practice Guidelines (BPG): • Developing & Sustaining Interprofessional Health Care: Optimizing Patients Organizational & System Outcomes • Supporting & Strengthening Families through Expected & Unexpected Life Events

BACKGROUND • St. Michael’s Hospital (SMH) strives to provide the highest quality of care for patients and families & promote safety • Providing high quality care & ensuring patient & family safety are important goals in the CIU The CIU staff wanted to know: • How well they were doing as a team • What they were doing well from the patient and family perspective • How they can improve the care experience for patients and their family • Are St. Michael’s core values & mission evident in the delivery of care?

METHOD • Survey was designed by CIU Best Practice Sustainability Champions and reviewed by: • Professional Practice • Patient and Family Education • Clinical Leader Manager (CLM), CIU • Physicians • Staff members of the CIU • Survey consists of: • 4 yes/no questions • 11 Likert-type scale questions: Strongly disagree / Disagree / Somewhat disagree / Neutral / Somewhat agree / Agree / Strongly agree • 4 categories: Compassion, pain control, communication with staff & communication with physicians • 3 qualitative-type questions • 100 surveys were distributed to patients or family members prior to discharge by clerical & nurses in the CIU and Cardiac Short Stay area • Surveys were administered over 6 weeks • (January – February 2016) • Completed surveys were placed in a sealed box in the CIU by the patient or family member

RESULTS (con’t)

RECOMMENDATIONS/NEXT STEPS

Communication with physician Communication with staff Pain control Compassion 0%

20%

40%

Compassion

Pain control

0 0 0 2 24 74

0 0.6 0.6 3.3 32.5 63

Strongly disagree Disagree Somewhat disagree Somewhat agree Agree Strongly agree

60%

80%

100%

Communication Communication with staff with physician 0 0.65 0 0 0 0 1.32 1.95 27.13 24.4 71.55 73

• Review & update pre-procedure information package • Work on more timely & effective communication with patients & family • Provide patient & family with consistent information regarding their plan of care • Engage physicians to ensure more timely communication to patients & families before discharge • Improve on the lack of physical space in CIU, and to get better stretchers in future • Liaise with the Patient & Family Advisory Council of the Heart & Vascular Program • To conduct frequent re-assessment and re-evaluation to ensure that current standards of care are maintained

REFERENCES •

Castle, N.G., Brown, J., Hepnex, K.A. & Hays, R.D. (2005). Review of the literature on survey instruments used to collect data on hospital patients’ perceptions of care. Health Research and Educational Trust. DOI: 10.1111/j. 1475-6773.00473.x

•

Ko, D.T., Donovan, L.R., Huynh, T. Rinfret, S. So, D.Y., Love, M.P., Galbraith, D., Tu, J.V. (2008). A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals. Health Outcomes/Public Policy. Canadian Journal of Cardiology. 24(11), November, 2008.

•

Kristin, L., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., Sweeney, J. (2012). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs. 32(2), 223-231.

•

Johnson, B.H., Abramson, M.R., Sheldon, T.L., Abramson, J.B., Shelton, T.L. (2009).

Patient and family-centered care: Partnerships for quality and safety. http://ncmedicaljournal.com.

•

Laurance, J., Henderson, S., Peter, J., Howitt, M.M., Al-Kuwari, H., Edgman-Levitan, S. & Darzi, A. (2014). Patient engagement: four case studies that highlight the potential for improved health outcomes and reduced costs. At the Intersection of Health, Health Care and Policy. Health Affairs. 33(9) 1627-1634.

Figure 1. Patient and Family Survey Responses

CONCLUSION • Overall, patients and families expressed a positive experience

PURPOSE & OBJECTIVES Purpose • To assess & evaluate patient & family satisfaction in the CIU Objectives • To develop a patient & family survey that will: • Assess patient & family experience & satisfaction with care • Improve CIU’s understanding of patient & family needs & experiences • Identify areas of improvement for the patient & family care experience

RESULTS • 78% response rate • Demographics: • Patient (75%) / Family (25%) / Unspecified (1%) • First cardiac procedure at ANY hospital?

• Yes (44%) / No (51%) / Unspecified (4%) • First procedure at St. Michael’s?

• Yes (61.5%) / No (32%) / Unspecified (6.5%) • Given info about visitor policy?

• Yes (85%) / No (1%) / N/A (11.5%) / Unspecified (2.5%) • Questions about visitor policy answered?

• Yes (78%) / No (1%) / N/A (14%) / Unspecified (7%)

• 27% (n=21) indicated “everything” when asked about what was done well • Areas of strength include: staff friendliness & compassionate care.

This is in alignment with the mission & values of St Michael’s • Areas for improvement include: • Communication throughout the whole experience (preprocedure, during and after) for both patients and families • Discomfort related to equipment & the lack of physical space • Pain control during & after the procedure

ACKNOWLEDGEMENTS • Victoria Buczek, CLM, CIU • Dr. C. Buller, MD, FRCP (Director Cardiac Catheterization & Intervention: Division of Cardiology) and CIU medical team • CIU Staff • Eddie Chu, external research analyst

Are We Meeting the Mark? Evaluation of Current Education Model for Post Kidney Transplant Patients Michelle Gabriel, RN, BsCN, cNeph(c) and Jonathan Fetros, RN, MN, CHE, Clinical Leader/Manager for Diabetes & Renal Transplant St. Michael’s Hospital

Introduction

Methods

•

1:1 interviews with post transplant patients at different times in the post transplant continuum

•

•

Renal transplant is the treatment of choice for end stage renal failure for most clients. Transplant recipients need to acquire a significant amount of knowledge for their life after transplant.

Patients report greater adherence when they feel their concerns, and knowledge deficits are addressed. It is also reported to increase patient satisfaction, improved quality of life, reduce anxiety, decrease uncertainty and facilitate transition phases

Facilitated 1 focus group of post transplant patients to gather insight into the post transplant journey Areas of Strength

•

• •

Meetings with post transplant RN’s were conducted to discuss results of the survey and discuss areas for improvement. There was consensus on the need for: • Better communication amongst nursing and inter professional team regarding patient education intervention, was required • Improvement in the consistency of documentation on the patient education provided • Development of standardized interventions Other ideas:

Previous reviews, in the literature, focus mainly on the patient education prior to transplantation. There is limited literature focusing on post transplant education

• Mandatory post transplant class for new recipients • Develop educational slides for waiting room TV • Develop detailed guidelines for standardized information so that it is clear what RN is to cover with patient “ clear, consistent messaging

Implementation and Evaluation of Best Practices of an Interprofessional Education Program for PostTransplant Patients •

Intervention/Process

9

Assess the current post transplant education model of transplant recipients.

It was decided as a group that the existing transplant database could be used to develop a documentation tool that would meet our needs:

To identify the educational needs of post kidney transplant recipients at St. Michael’s hospital through out their transplant journey.

Address the needs of patients that are English as a Second Language Align education practices with RNAO best Practice Guidelines on Establishing Therapeutic Relationships & Developing & Sustaining Interprofessional Health Care

Establishing Therapeutic Relationships

• The nurse must acquire the necessary knowledge to participate effectively in therapeutic relationships • Establishment of a therapeutic relationship requires reflective practice.

Recommendations

Areas to Improve

•

to standardize the material we were teaching to patients

•

provide communication between team members

•

simplify charting.

Conclusion • A variety of useful information was collected from post transplants along the care continuum. It challenged some of the assumptions that we had about our patients needs.

• As an interprofessional team, we identified that in order to create more meaningful patient experiences we need to be consistent on our care.

This can be achieved with improved communication between team members & provided standardized guidelines for practitioners to use in their practice.

• Validated that some of the current methods of delivery are working well.

Patients overall feel respected & part of the team. The further patients are from transplant the more confident they are in living with their transplant.

Next steps……

• Create database screens to assist with documentation, communication & standardization(PDSA #1) Currently in process.

• Undergo a trial period of 6 weeks (PDSA #2) – evaluate whether it is still thought to be useful, how can it be improved, did we miss anything the first time. Work with team to continue to evaluate tool. (end of May 2016) • Develop detailed guidelines to match topics covered under each subheading – ensure that each health practitioner that comes into contact with patient is sending a similar message. Create information packages with written material in enforce what was discussed (coincide with time points in continuum of care). June – August 2016.

It was decided that it would be best to develop education topic checklists based on time points of patient follow up post transplant.

• Complete patient surveys again in 1 years time to measure if change in RN practice has made an impact. May 2017

Every patient encounter, from discharge to years post transplant, should have an educational component. This is common practice, but there is no documentation currently to support the practice.

• Continue to engage patients through post transplant symposium already in place. Spring & Fall annually.

• Conduct further research in this area. It is not only applicable to SMH but also other transplant programs in Canada and abroad References 1. Myers, J. and Pellino, T.. Developing new ways to address learning needs of adult abdominal organ transplant recipients. (2009) Progress in Transplantation (19)2,160 -166.

2. Schmid-Mohler, G.,et al. A mixed-method study to explore patients’ perspective of self-management tasks in the early phase after kidney transplant. (2014) Progress in Transplantation, 14(1), 8-18.

Developing & Sustaining Interprofessional Health Care

• Interprofessional care partnerships agree on an evidence-based approach to planning, implementation, and evaluation activities.

• Promote interprofessional care by developing a culture that expects collaboration • All health-care professionals demonstrate their commitment to the principles of interprofessional care

3.Urstad, K. et al. Renal recipients education experiences in the early post-operative phase – a qualitative study.

(2012) Scandinavian Journal of Caring Science, 635-642.

4. Urstad, K., et al. Limited evidence for the effectiveness of educational interventions for renal transplant recipients.

Results from a systematic review of controlled clinic trials. (2013) Patient Education and Counseling (90), 147 – 154.

Interprofessional Care Planning for Inpatient Mental Health Sarah Beneteau BScN, RN St. Michael’s Hospital

FOCUS

RESULTS

INTERVENTION/PROCESS

Development and implementation of individualized care plans on the inpatient mental health unit, which align with recommendations from the RNAO Person and Family Centered care Best Practice Guideline (2015).

Post Intervention Goal Setting Completion

Quality Improvement Strategy

RECOMMENDATIONS/NEXT STEPS Ongoing audits of care plan quality, and documented patient engagement.

13%

BACKGROUND •

The current process of care planning on the inpatient mental health unit functions poorly. As a result, Care plans are inconsistent or absent. Staff use various kinds of signage and alert sheets to enhance continuity of care or act as a care plan

•

On initial audit, care plans were being completed 45% of the time

•

There were 5 different places care plans could be found on the unit, including taped to the nursing station window, in a shared drive on the computer, or in the patient’s chart

• •

There was no way to document that a client had been involved in the care planning process Focus groups were completed with stakeholders to understand important aspects of care planning on 17cc DISCIPLNE Registered Nurses

FOCUS GROUP THEMES Nursing staff reported that the current process creates too much double documenting. They stated that the current care plans and are not accessible or easily updated. Some staff report not ever looking at the care plan, and not knowing where it was.

Allied Health

Allied health staff perceived that more consistent use of interdisciplinary care plans would increase continuity of care, and enhance communication among team members. It was felt that care plans should include a section for Allied Health staff to make additions

Physicians

Physician team members emphasized a need for consistency of communication between staff on the unit. It was important for the document to be easily modified and located.

Peer Support

Peer support staff agreed that they have information about patients that is helpful for the team to know, and that it would be valuable to have a place to share this information where staff would see it

Patients

Overall, patients reported feeling satisfied with their level of involvement in their care. Patients felt that staff were usually on the same page, with a few exceptions Patients across the board reported the most important aspect of feeling heard and involved was the amount and quality of time their nurse spent with them.

PURPOSE & OBJECTIVES Using this tool we plan to have an individualized care plan completed for 100% of clients admitted to the Inpatient Mental Health Service by March 23rd 2016. Documented patient engagement in the goal setting section will be measured.

INTERNAL SCAN November 17th 2015

EXTERNAL SCAN November/ December2 015

LITERATURE REVIEW December 1st16th 2015

DRAFT CARE PLAN TEMPLATE January 5th 2016

TEST CHANGE USING PDSA CYCLES January13t h-27th 2016

REVISE & FINALZIE CARE PLAN February 2nd 2016

“GO LIVE” DATE March 1st 2016

87%

Further edits can be made through medical records as the document is used and staff provide further feedback

• Staff feel this is a thorough and concise way of communicating the most important information about a patient • The care plan is based off of the Ontario Medical Association “Elements of a Coordinated Care Plan”

• Staff report that goal setting is an effective way to involved patients and families in the care planning process, in an acute care setting

• It is a bi-fold piece of cardstock paper

• Nursing staff report the new care planning tool fills a gap in communication, and eliminates the need to double and triple document important information about a patient so that it does not get missed

• First page consists of general information and demographic data, and includes a brief history of present illness. The alerts section includes common safety alerts and room for additional things that are important for staff to know • Second page includes nursing diagnoses or concerns, and interventions • Third page includes patient’s stated goals during their admission, in SMART format • Fourth and final page is a medical summary. This page includes common medical issues we see on 17cc and room to add additional ongoing issues

• Barriers to completing the goals section of the care plan were discussed. Nursing staff report that many patients refuse, or are unable to set goals at this time. It is also a new part of work flow and clinical time which may take longer to catch on

CONCLUSION • There has been a 55% increase in the amount of care plans being completed by the staff on 17cc. Staff are documenting goal setting (patient engagement) 13% of the time.

• Although staff are completing care plans for patients 100% of the time, the patient is not consistently being engaged in this process by goal setting with the team • During post intervention audits on March 22nd, it was found that some care plans are not being updated consistently or thoroughly, and some use of the random alert sheets and informal care planning still exists although it is very limited

Engagement of Peer Support and OT staff to help complete goal setting section with patients, further coaching for nursing staff regarding this aspect of the care plan

REFERENCES College of Nurses of Ontario (n.d.). Retrieved January 19, 2016, from http://www.cno.org/en/learn-about-standards-guidelines/standardsand-guidelines/ Key Elements to Include in a Coordinated Care Plan. (2014, June 1).

Retrieved January 19, 2016, from https://www.oma.org/Resources/Documents/CoordinatedCarePlan_J une2014.pdf Registered Nurses' Association of Ontario. (2015). Retrieved January 19, 2016, from http://rnao.ca/bpg/guidelines/person-and-familycentred-care

ACKNOWLEDGEMENTS This project was funded by Nursing Practice and Education, Professional Practice.

Special Thanks to the staff on 17cc Inpatient Mental Health, Laura Jackson, Murray Krock, and Nicole Kirwan for their support and input into this project.

QI Initiative: Improving Transfer of Accountability in the Palliative Care Unit Slawomir Zulawnik RN BN and Victoria McLean RN BScN

BACKGROUND

OBJECTIVES

The progression of life limiting illness to death, often presents challenges in the way to deliver Transfer of Accountability (ToA) in the Palliative Care Unit (PCU) due to:

1. Establish guiding principles for ToA in the PCU based on the current evidence-based practice standards and norms in Palliative Care.

• Intensified symptoms such as anxiety, pain, fatigue, dyspnea, agitation, delirium, and existential distress, which often are an inherent part of a dying process

2. Create a new standardized tool in order to improve the quality and quantity of information shared during ToA. The new tool will reflect the current state of documentation in the organization (charting by exception) as it is an efficient way to impart information.

• Emotional suffering associated with the grieving process • Energy conserving techniques employed by the patients to continue meaningful interactions with family and friends • Patient care centering on relieving suffering and improving quality of life

CURRENT STATE Staff discussion and examination of previous ToA audits revealed that ToA at the bedside was inconsistently completed and not grounded in the philosophy of the PCU. In addition, the initial standardized tool was not being used effectively for information sharing during Transfer of Accountability.

INTERVENTION 1. Guiding Principles for ToA in the PCU • ToA is conducted in accordance with the organizational guidelines and the philosophy of care in the PCU. It is supported by practice standards/guidelines used in Palliative and End-of-Life Care and governed by values of autonomy, self-actualization, dignity and community (CHPCA, 2013).

Some driving ideas behind the philosophy of care in PCU are that well-being, quality of life, and relief from suffering are paramount.

INTERVENTION (continued) • A nurse may use clinical judgment to pre-determine if the patient requires a minimal stimulus environment (e.g. frequent seizures, severe anxiety/agitation, need for energy conservation). If this is the case and a Substitute Decision Maker (SDM) is present, he/she will be still invited to participate in ToA away from the bedside. The bedside safety check must still be completed.

• If there is a need for debriefing between nurses, it will be done separately from the ToA process, away from the bedside.

2. The new standardized tool for ToA is now in use and was designed to impart information more effectively, succinctly and consistently. A formal evaluation is currently underway NEW ToA TOOL for PCU

REFERENCES Canadian Hospice Palliative Care Association. (2013). A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice. Retrieved March 9, 2015, from http://www.chpca.net/media/319547/norms-of-practice-eng-web.pdf Canadian Nurses Association. (2012). Hospice Palliative Care Nursing Certification Exam List of Competencies. Retrieved March 9, 2015 from http://nurseone.ca/~/media/nurseone/files/en/cert_hospice_2012_e.pdf#page=10?la=en

• As per CHPCA (2013), a nurse will ensure that the patient and/or family are coping appropriately. Bedside ToA may be discontinued, based on the ethical principle of nonmaleficence if undue burden is perceived. This will be determined by a nurse’s clinical judgment. Common reasons for undue burden may include unmanaged symptom burden (e.g. pain crisis, severe dyspnea), increasing anxiety, existential distress, etc..

•

If the ToA process is discontinued at any time, the reason must be clearly documented in an interprofessional note as per organizational policy. The bedside safety check must still be completed and the remaining ToA process will be completed away from the bedside.

• A nurse will know the clinical indicators of decline and model patient care appropriately. Bedside ToA will not occur during the time of imminent death, respecting the family’s privacy and need for closure. The bedside safety check must still be completed.

College of Nurses of Ontario. (2009). Professional Standards. Retrieved March 9, 2015, from http://www.cno.org/Global/docs/prac/41006_ProfStds.pdf Hopkinson J. The hidden benefit: the supportive function of the nursing handover for qualified nurses caring for dying people in hospital. Journal of Clinical Nursing. 2002;11(2):168-75.

Messam K, Pettifer A. Understanding best practice within nurse intershift handover: what suits palliative care? International Journal of Palliative Nursing. 2009;15(4):190-6.

Registered Nurses Association of Ontario. (2011). End-of-Life Care During the Last Days and Hours. Retrieved March 9, 2015, from http://rnao.ca/sites/rnao-ca/files/End-of-Life_Care_During_the_Last_Days_and_Hours_0.pdf Smith L, Gale S, Glynn J, Tank S, Newberry L, Graham M. Improving nursing handover in a specialist palliative care unit.

BMJ Supportive & Palliative Care. 2012;2(Suppl 1):A81.

St. Michael’s Hospital. (2014). Policy - Intershift Nursing Transfer Of Accountability.

Wildner J, Ferri P. Patient participation in change-of-shift procedures: the implementation of the bedside handover for the improvement of nursing quality in an Italian hospice. Journal of Hospice & Palliative Nursing. 2012;14(3):216-24.

EVALUATION AND SUSTAINABILITY PLAN Acknowledgements 1. Continue to use the corporately rolled out audit tool to monitor compliance with ToA. 2. Feedback from nurses is being used to evaluate the new standardized tool.

3. Short survey to evaluate staff perception of new ToA process.

We wish to acknowledge the support of our Clinical Leader Manager, Anna Kacikanis.

Improving the Quality of Suicide Risk Assessment in the Mental Health and Addictions Service through Ongoing Professional Development Sarah Fabro RN, BScN, MN, CPMHN(c) St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS

PROCESS & INTERVENTION

Content Development

The focus of this project was to provide all interprofessional clinicians in the Mental Health and Addictions Service with ongoing professional development on the topic of suicide risk assessment.

Learning Needs Assessment

•

RNAO Best Practice Guideline: Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour. (RNAO, 2008).

BACKGROUND

Stakeholder Interviews n = 2 staff

Focus Groups n = 21 staff

• It had been several years since the last booster training • Chart audits revealed that documentation of risk assessment may not always reflect best practices in suicide risk assessment • Accreditation Canada: Suicide Risk Assessment is a Required Organizational Practice

PURPOSE & OBJECTIVES GOAL To design and deliver a suicide risk assessment booster training to all interprofessional clinicians in the Mental Health and Addictions Service.

OUTCOME INDICATORS • Number of clinicians who complete booster training on suicide risk assessment • Clinician confidence and competence in suicide risk assessment post training • Clinicians indicate that training met their learning needs

Staff Survey Online

n = 9 staff

n = 71 staff

• • •

Key Themes Presented in Hour Long Booster Training Session We Asked: What practice gaps, if any, can you identify related to your skills in assessing suicide risk?

RNAO BPG Recommendation 15 Nurses who work with individuals at risk for suicide must have the appropriate knowledge and skills acquired through basic nursing education curriculum, ongoing professional development opportunities and orientation to new work places (RNAO, 2008).

Individual Interviews

External Scan of professional development content on suicide risk assessment Meeting with subject matter expert RNAO Best Practice Guideline review Literature Searches

“Our practice has been so focused on check lists in assessments that conversation with patients are missing.

This leads to missing the cry for help and what patients are saying, and simply focus on check mark on a form. There are multiple parts to suicide risk assessment, currently there is a focus on one part; "are you thinking of ending your life"

“Documentation of risk assessments and interventions”

• • • • •

Review of SMH policy on risk assessment Assessment review of warning signs, risk and protective factors Strategies to ensure for immediate client safety and safeguarding of the environment How to be a better intervener and strategies to instill hope Documentation standards and legal implications of working with a client at risk for suicide Clinician Response to: What will you change as a result of this training? (free text)

“Developing enough rapport in a brief interaction that allows for a full risk assessment”

• 27 clinicians independently reported that they will improve the way they document risk assessments after this education

RESULTS We Asked: What would you like to learn more about?

Check all that apply.

9 booster trainings done from March – April, 2016.

82 of 117 clinicians educated; 70% of Mental Health & Addictions staff.

Participants completed a post training evaluation.

Clinician Response to: My learning needs were met.

“Identify level of risk, low vs. high”

“Better, more detailed documentation”

“More discussion time, fostering hope”

RECOMMENDATIONS/NEXT STEPS • Ensure that all staff continue to receive booster training on a regular basis; consider more frequent sessions, every 2 years as requested by staff • Random chart audits to assess quality of documentation.

ACKNOWLEDGEMENTS A special thank you to Nicole Kirwan, Murray Krock & Ashley Skiffington for their guidance and support throughout this project.