N E W S & V I E W S
Issue 3 July-September 2011
Quality and Safety: The Positive Effect of Open Communication By: Christine Byerly, BSN, RNC-NIC, SCN II, NICU & Paul Thurman, MS, RN, ACNPC, CCNS, CCRN, CNRN, CNS, STC It is not characteristic for members of the healthcare team to delibconsecutively and/or concurrently so that one day, at one time, all erately decide, “Today I am going to make an error.” On the conthe “holes” line up and a serious event results.2 trary, medical professionals and healthcare leaders strive to provide a Open communication about errors promotes a transparent culture safe environment for our patients; one leading to the development of prothat is “error free”. However, death Swiss Cheese Model cesses and systems to enhance patient from medical errors ranks between the safety. Asking the question, “What Level of Defense 5th and 8th leading cause of death1. have we done to harm or almost harm When we reflect on errors, it is customa patient?” has changed patient care ary to find fault and blame the indiat UMMC. This question is posed at vidual. This “blame game” leads to an the beginning of all council and leadunder reporting of events. Most errors ership meetings within Patient Care do not occur in isolation. Instead, an Services. This process was initiated by error that one person makes will make Lisa Rowen, DNSc, RN, FAAN, Chief an impact on someone else. Nursing Officer. Errors are caused by faulty systems, Latent conditions: An example of the effectiveness of poor design, procedures, Active errors processes, and conditions that lead management decisions, etc. asking this question has occurred in (Patient safety incident) people to make mistakes or fail to prethe Staff Nurse Council, co-lead by vent them. A graphic example of this Dr. Rowen and Chris Byerly. From concept is depicted in the Swiss Cheese Model. In this model, when this question, numerous patient safety issues have been raised, such a combination as Alaris™ infusion pump malfunctions, missing medications, In This Issue... of latent condiOmnicell™ dispensing issues, inconsistent dose range checking tions and active Quality and Safety - The Positive Effect of Open Communication 1, 6 practices, and missing laboratory specimens. These issues would errors causes all Lisa Rowen’s Rounds 2 have never surfaced without staff speaking up and identifying the levels of defenses CODE STEMI: This is a Medical Emergency 3 problem. This led to the realization that these were system-wide to be breached, Moderate Sedation Simulation 4 problems involving more than one individual and prompted the a patient safety Professional Advancement Model 5 Staff Nurse Council to take further action. In collaboration with incident occurs. Biomedical Engineering, there is a new process in place for cleaning Along the Path to Advancement 5 When such inciinfusion pumps to prevent the identified error. A Lab Integration Commitment to Excellence 6 dents occur, it Team has been formed to educate nursing about how laboratory The First New Graduate Nurse Residency Projects 7 is uncommon results are obtained. The Pharmacy has implemented new processes Five Infection Prevention Practices That Matter 7 for any single for Omnicell™ dispensing and dose range checking. In addition, UMMC Nurses Organize Community Health Fair 8 action or “faila new pilot is starting in the Gudelsky tower to ensure delivery of ure” to be wholly Honorable Mention 9 medication to the correct storage location (i.e. patient bin, refrigeraresponsible. It Certification Corner 9 tor, medication cart) by a dedicated pharmacy technician. is far more likely Core Measures 10 In the 2005 study, “Silence Kills”, it was reported that 84 percent of that a series of Clinical Practice Update 11, 12 healthcare professionals observe colleagues take dangerous shortcuts seemingly minor We Discover 11 events all happen see Quality and Safety on page 6 News & Views
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Lisa Rowen’s Rounds Scope of Practice, Autonomy and Control over Nursing Practice Scope of practice refers to the nursing care and practice that can be provided legally within the limits of the Nurse Practice Act outlined by the Maryland Board of Nursing and is defined by the nurse’s educational qualifications and specific experiences (Weston, 2010). Over the past several months, we’ve had a lot of discussion about the notion of scope of practice. This topic has been discussed in our councils, patient care areas and at Nursing Grand Rounds. On occasion, I’ve heard comments like “We are a Magnet hospital and Magnet nurses are supposed to be autonomous. How can I be autonomous if my scope of practice is limited?” An important element of nursing autonomy is providing nursing care within our scope of practice. The concepts of autonomy and scope of practice are not mutually exclusive. In fact, autonomy cannot exist unless a nurse is within his or her scope of practice. If a nurse knowingly practices outside of the defined scope, he or she is practicing a different discipline, such as medicine. This type of practice would be considered illegal.
Autonomy refers to a nurse’s ability to act according to his or her knowledge and judgment, while providing nursing care within the full scope of practice as defined by existing professional, regulatory and organizational rules (Weston, 2008). In a 2003 study of nurses in Magnet facilities, Kramer and Schmalenberg found nurses described their culture as supporting autonomous practice, where they were expected and encouraged to use their nursing expertise to deliver the best possible patient care. Nurses can help drive professional and organizational expectations that determine the degree to which autonomous practice occurs through control over nursing practice (Weston, 2008). The shaping of departmental and organizational policies and practices related to nursing care demonstrates control over nursing practice. When nurses have high levels of control over nursing practice, they have the responsibility and opportunity to provide input and make decisions related to their practice. This ultimately leads to work environments with increased performance and improved patient outcomes (Kramer & Schmalenberg, 2003a). Work environments with higher levels of autonomy and control over nursing practice are foundational for higher levels of patient safety (Institute of Medicine, 2004).
Table. Strategies for Enhancing Autonomy and Control Over Nursing Practice 1. Strategies for Enhancing Autonomy a. Clarify expectations about clinical autonomy i. Describe expected behaviors ii. Embed nursing knowledge into clinical practice processes iii. Recognize and reward autonomous practice iv. Role model expected behaviors v. Coach nurses not demonstrating expected behaviors vi. Provide manager support for autonomous practice b. Enhance competence in practice i. Create a learning environment ii. Enable formal and informal educational opportunities 2. Strategies for Enhancing Control Over Nursing Practice a. Establish participative decision making i. Use an organized structure for nurse participation in decision making ii. Ensure authority for clinical decision making resides with direct care nurses iii. Include nurses on organizational committees iv. Minimize bureaucracy v. Support involvement by nurses on committees and workgroups b. Enhance competence in decision making i. Teach nurses about the decision-making process ii. Coach and support nurses through early decisions iii. Teach facilitation skills to leaders 3. Strategies for both Autonomy and Control over Nursing Practice a. Ensure strong nurse leaders i. Create strong, visible, nurse leaders ii. Ensure that nurses in supervisory positions are encouraging autonomy and control over nursing practice iii. Have executives advocate for influential nursing practice iv. Encourage new and innovative ideas b. Work upstream i. Influence social, political, and economic factors ii. Publicly describe nursing’s unique expertise and contribution iii. Acknowledge nurses’ contributions in all roles and practice settings iv. Use political clout of professional organizations and nurses in leadership roles. Weston, 2010. Reprinted with permission of the author.
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Our goal is to maximize nurses’ autonomy by practicing to the limits of our scope, clarifying expectations about clinical autonomy and enhancing competence in practice. In addition, we will continue to enhance our control over nursing practice through collaborating in participative decision making, enhancing competence in decision making, and creating strong nurse leaders. These goals will be supported by continuing the discussion about scope of practice so clinical challenges, such as receiving verbal orders on rounds, can be shared and addressed. This practice will create criteria driven clinical protocols that can be initiated by a licensed independent provider when a nurse advocates for a patient who meets the criteria. How can we continue to enhance UMMC nurse autonomy and control over nursing practice? Marla Weston, the Chief Executive Officer of the American Nurses Association, suggests many excellent strategies for doing just this (see Table). I think we need to consider the strategies Weston outlines, assess our current state regarding each one, and continue on our path as a Magnet institution where nurses exemplify autonomy and control over nursing practice. References: Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press. Kramer, M. & Schmalenberg, C.E. (2003). Magnet hospital staff nurses describe clinical autonomy. Nursing Outlook, 51, 13-19. Kramer, M. & Schmalenberg, C.E. (2003a). Magnet hospital nurses describe control over nursing practice. Western Journal of Nursing Research, 25, 434-452. Weston, M.J., (Jan., 2010). Strategies for enhancing autonomy and control over nursing practice. OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 2. Weston, M.J. (2008). Defining control over nursing practice and autonomy. Journal of Nursing Administration, 38, 404-408.
News & Views is published bimonthly by the
Department of Nursing & Patient Care Services of the University of Maryland Medical Center Scope of Publication • Clinical and professional nursing practice in inpatient, procedural, and ambulatory areas that is evidence-based, innovative, and outcomes driven. • Focus on divisional, departmental, and/or organizational strategic goals. Guidelines for Article Submission 1. Times New Roman - 12 pt black font only. 2. Length - three double spaced, typed pages maximum. 3. Include name, position title, credentials, and practice area for all writers. 4. Credentials must be provided for anyone named in the article. 5. Proofread article for spelling, grammar, and punctuation before submitting. 6. Provide photos in .jpg format. 7. Send completed articles via e-mail to email@example.com. 8. Editor will seek expert review of articles to verify and validate content.
CODE STEMI: This Is A Medical Emergency By: Christi Harrell, BSN, RN, SCNI, Cardiac Catheterization Lab The CODE STEMI Alert is the emergency process for patients with acute heart attacks; these patients need to get to the Cardiac Catheterization Lab 8-6618 within 30 minutes of abnormal ST segment EKG Step 1 – Perform An EKG
Highlighted area is ST segment; used to recognize normal versus abnormal
9. Submit trend data in graphic format with labeled axes. Please send all News & Views articles to Anne Naunton via email firstname.lastname@example.org. Please follow the submission requirements that are published in each issue of News & Views.
￼ This is ST ELEVATION and needs Emergent Medical Attention
Editor Anne E. Naunton, MS, RN Professional Development Coordinator Clinical Practice and Professional Development Editorial Board Lisa Rowen, DNSc, RN, FAAN Senior Vice President and Chief Nursing Officer Nursing and Patient Care Services
This is ST DEPRESSION and needs Emergent Medical Attention
Ann E. Regier, MS, RN Director Clinical Practice and Professional Development
Step 2 – MD/NP read EKG within 10 minutes
Kristin Seidl, PhD, RN Director of Outcomes Nursing and Patient Care Services
Step 3 – The correct number to page Cardiology Consult is 410-389-2562, type 911 after your extension to emphasize potential CODE STEMI.
Angela Sintes, MS, RN, CNL Clinical Education Specialist Clinical Practice and Professional Development
Step 4 – Interventions; only if time allows, DO NOT DELAY TRANSPORT:
Susan S. Carey, MS Professional Development Coordinator Clinical Practice and Professional Development
Plain Aspirin 325mg (once ordered), Oxygen 2L Nasal Cannula, IV Access Step 5 – If after working hours (after 5:30 p.m. weekdays and anytime on weekends or holidays), the on-call team will be on their way in to the hospital. The CCU bridge team 8-5426 will be available to accept the patient in the Cath Lab on 3rd Floor South Building.
TIME IS MUSCLE
Moderate Sedation Simulation: An Innovative Approach to Teaching Safe Patient Care By: Meredith Huffines, BSN, BA, RN, SCNII and Rachel Maranzano, BSN, RN, CCRN, SCNI and Lena Stevens, MSN, RN How do we teach our new staff members to safely perform a low occurrence procedure that brings high risk to the patient? This was the question Meredith Huffines, BSN, BA, RN, and Rachel Maranzano, BSN, RN, CCRN of the Surgical Intensive Care Unit (SICU) asked when developing orientation for new staff members; in particular, when addressing moderate sedation. Most patients in the SICU require mechanical ventilation, therefore moderate sedation is not needed. Consequently, there are few opportunities for new SICU nurses to learn and apply the knowledge and skills necessary for moderate sedation. At times, moderate sedation is needed for patients who require procedures and are not on the ventilator. Moderate sedation is a medically controlled state of depressed consciousness. In this state, the patient has positive protective airway reflexes, spontaneously ventilates, and responds purposefully to stimuli. Performing moderate sedation for a procedure requires the RN to manage the patient’s safety. Knowledge, skill, and educational preparation are needed for a nurse to be competent in moderate sedation. Competency includes administration of moderate sedation, monitoring the patient during the procedure, and recovering the patient from the sedation. Some examples of procedures where moderate sedation may be used are central line placement, PEG placement, EGD, painful dressing change, CT, and MRI. In collaboration with the MASTRI simulation lab staff, including former MASTRI Director, Dr. Gerald Moses, former Training Specialist Sheree Chase, MSN, MBA, RN, and Simulation Educator, Kerry Murphy, DVM, we developed an exciting didactic and hands on learning experience on moderate sedation. The literature describes the use of simulation as a meaningful, effective and efficient learning environment that helps to address the learning styles of a multigenerational work force (Notarianni, CurryLourenco, Barham & Palmer, 2009). It is a useful approach for developing interactive critical thinking in a safe and risk free environment (Medley & Horne, 2005). Given that the literature supports using simulation as a teaching strategy, we decided to develop a moderate sedation simulation class for our new nurses. Our goal in developing this class was to give nurses real life experiences of performing moderate sedation in the form of complicated case scenarios. In return, our nurses applied critical thinking and learned to appreciate the associated risks of moderate sedation. The
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MASTRI Center created a safe learning environment for simulation. We assessed the nurses’ knowledge and skills in moderate sedation by direct observation. A prerequisite for the moderate sedation simulation class was the completion of the adult moderate sedation module and test located in Healthstream. We organized didactic material to review in the beginning of the class which included our UMMC hospital policy, education material on sedation, and hospital forms necessary to perform moderate sedation. We developed case scenarios, objectives for the class, participant roles, learners’ achievement checklist, pre and post tests, debriefing points, and course evaluations. The class evaluations and verbal responses for the six classes we conducted were very positive. When asked “After attending the class, I now feel comfortable with moderate sedation,” the participants rated this question 4.8 out of 5. And the question “The use of simulation enhanced my learning,” elicited a score of 4.8 out of 5. When asked “This training session was effective and I would recommend it to others who will perform this skill in clinical practice,” the participants scored this question 4.9 out of 5. Participants gave positive feedback about the use of realistic scenarios. “The simulation helped to get me thinking about what I’ll do in these situations. The practice was very helpful.” They also appreciated the opportunity to debrief and review the experiences they encountered in the simulation. Due to its success, this class was shared in hospital committees. Many peers were interested in using the simulation as the teaching tool for their new nurses. Unit educators observed the SICU moderate sedation class and tailored it to meet their unit’s needs. In collaboration with Clinical Practice and Professional Development and Lena Stevens, MSN, RN, a hospital wide moderate sedation course with simulation was developed. The class is currently offered every other month. Every staff member is able to register through Healthstream. Once the Healthstream module is complete, participants can attend the simulation for hands on experience. References: Notarianni, M., Curry-Lourenco, K., Barham, P., & Palmer, K. (2009). Engaging learners across generations: The progressive professional development model. The Journal of Continuing Education in Nursing, 40(6), 261-266. Medley, C. & Horne, C. (2005). Using simulation technology for undergraduate nursing education. Journal of Nursing Education, 44(1), 31-35.
Professional Advancement Model Congratulations to the following nurses promoted in January, April, and July of 2011: Senior Clinical Nurse I Amy Grier, BSN, RN, CCRN – Cardiac Intensive Care Unit (CCU) Carolyn Wirth, BSN, RN, CCRN – Pediatric ICU Jennifer Bethel, BSN, RN, CCRN – Medical IMC Mandy Ervin, BSN, RN – Progressive Care Unit Megan Ubik, BSN, RN, OCN– Bone Marrow Transplant Naomi Nicdao, BSN, RN – 11 East Richard Bell, BSN, RN, CCRN – Cardiac Surgery ICU Tammy Barton, BSN, RN, CCRN – Medical ICU Elizabeth McDavid, BSN, RN – Multitrauma Chad Schrier, BSN, RN, CEN – Adult Emergency Sarah Horwath, BSN, RN, CCRN-CSC – Cardiac Surgery ICU
Parayil K. Sibi, BSN, RN, CCRN, CSC – Cardiac Surgery ICU Kristi Bagal, BSN, RN – Cardiac Surgery ICU Xiabo Hu, RN, CCRN-CSC – Cardiac Surgery ICU Sheila Lee, BSN, RN, ACRN – Evelyn Jordan Center Bruce Sisk, BSHA, RN – General Operating Rooms Holli Weaver, BSN, RN – Pediatric ED Veronica Brock, MS, RN – Surgical IMC Juanito “June” Guadalupe, BSN, RN, CEN, CCRN, CMC – TRU Carol Summers, BS, ADN, RN, RNC – Neonatal ICU Amber Lloyd, BSN, RN, CPN – Pediatric Surgery Center
Senior Clinical Nurse II Cynthia Bauer, MS, RN, CCRN - Cardiac Intensive Care Unit (CCU) Diane Constantine, BSN, RN, CPN - Radiology/Pediatric Sedation Janet Braun, BSN, RN, CPN – Radiology/Pediatric Sedation Karen Cossentino, MS, RN, CCRN – Cardiac Intensive Care Unit (CCU)
Maridulce Fortuno-Shifflett, BSN, RN, CAPA – Endoscopy Lab Dennis Brumbles, BSN, RN-BC – Adult Psychiatry Ariel de Vera, BSN, RN, CCRN – Medical ICU
Along the Path to Advancement: The Perspective of a UMMC Nurse By: Jennifer Miceli, BSN, RN, SCN I, Radiology Nursing/PICC Team I love the nursing profession. I am currently working as a nurse placing PICC lines and have done so for seven years now. I do believe that I have found my niche in nursing, I am where I need to be, and I am doing the things that I love to do. I am here to advance the practice of nursing in the vascular access area. So how do I do this, and where do I start? Sure I have great ideas, but I need to harness these ideas into actions and focus on the plan. My role in nursing keeps me involved with projects, active in two committees, and identified as a resource for vascular access. I am a preceptor, attend professional conferences, and consider myself to be an invaluable member of the PICC team. Then one day my nurse manager asked me, “Why aren’t you a Senior Clinical Nurse yet?” This was a good question, and one that brought me to the conclusion that I should advance “along the path.” This was the first step in the process. The next step along the path was to develop my portfolio. Some of this proved to be quite challenging. However, I knew this would be a valuable exercise, and I would generate a resource that I could use and build upon for the rest of my career. I found that the more information the better, and that this was my time to shine. The final step along the path was to place the information in a binder. Then I went to the Office of Clinical Practice and Professional
Development to personally deliver my masterpiece. They confirmed that the proper information was in the binder. Doesn’t this sound easy? Well, it wasn’t that difficult. If I had to do it over again, I would do two things differently. First, I would have used the portfolio submission checklist much sooner. I did not utilize it until the last day and was scrambling around because I forgot something. So I would recommend that this be used as a running check off list. Second, I would have applied so much sooner. Basically, I had been doing all these projects and met all the requirements, but I was not getting the professional credit for it. When I completed everything and turned it in, I felt an extreme sense of accomplishment. An interview was scheduled, and I’ll admit that I was nervous. However, I had the opportunity to discuss vascular access, one of my favorite subjects. After the interview, I felt wonderful, accomplished, and re-energized. A few days later my nurse manager called to inform me that I was promoted to a Senior Clinical Nurse I position. Now I am working toward the Senior Clinical Nurse II position. I will not procrastinate this time. So, my advice to anyone thinking of traveling along the path to advancement is to use the checklist, feel confident in your abilities, and just go for it. The reward is amazing.
Commitment to Excellence: Nursing Feedback Counts By: Eva-Lynn Stevens, MS, RD, LDN, Assistant Director, Food Hospitality Services Valorie L. Sanders, MSCP, NCC, Training, Strategy & Compliance Coordinator In April 2010, the University Of Maryland Medical Center (UMMC) embarked upon a significant service transition that would ultimately impact people, processes, and patient care—the transition of the food service operation from a contractor service to an in-house production. The transition birthed a spirit of revitalization and transformation as the operation became called “Food Hospitality Services (FHS).” Observers may have initially categorized the transformation merely as a change in name. However, those in the trenches quickly realized that the transition was an immediate call to a renewed commitment to service excellence. It required more focus on patient care needs, customer relationships, operational structure, and efficient and effective operational processes. In February 2011, during Dr. Lisa Rowen’s “Breakfast with Staff”, nurses used their voices to advocate for a more improved FHS experience for their patients. In the midst of expressing their concerns, a group of nurses decided to enhance their words with actions and they extended a chair, at the table of dialogue and feedback, to the department’s leadership team. On Monday, April 21, 2011, a group of nurses with leaders of Food Hospitality Services began a dialogue that yielded an understanding of customer concerns, departmental challenges, and the need for improved communication and education by the department with its customers. Operational inefficiency of the department became a shared concern for nursing, as it became very clear that patient care was being impacted. The operation had outgrown its kitchen, the hub of the operation. The increased volume of patients within the Medical Center had significantly impacted the amount of time it took to prepare and deliver patient meals. In addition, the high census and addition of
new patient care units raised the ratio of patients to Meal Attendants, well above the industry standard, further increasing the time it took to deliver a patient tray. The need to expand the tray line became apparent. Key computer interfaces were not synchronized and fully operational, thus contributing to operational inefficiency. Following a dialogue about these concerns, nursing staff were invited to join the department’s leadership team on a tour of the operation. The “realtime” observation provided nursing staff an opportunity to experience the intricacies of the department, see the confines of the operation, and the post-transition improvements, and to understand the potential impact of future operational plans. At the onset of the transition, it was obvious that FHS needed to overcome many challenges; yet, the post-transition improvements of the department were not always immediately visible. During the course of the 12 months following the transition, the operation has experienced many significant improvements that are expected to demonstrate service excellence by improving operational efficiency, as well as customer and patient satisfaction. Nursing and patient feedback articulated dissatisfaction with the temperature and quality of food. As a result, a new tray line was purchased, serviceware was upgraded, and recipes were refined. Nursing feedback also expressed the need for improved communication, as well as service recovery efforts by the department. In response, departmental leaders implemented chef rounding to assist with educating unit staff on the operation’s communication channels and addressing their immediate needs. Assistant managers are deployed as FHS liaisons to address the needs of specific units as needed. For additional information, please contact Mark Washenko, Food Service Director, via email email@example.com.
Quality and Safety from page 1 when working with patients, and yet less than ten percent speak up about their concerns. These shortcuts bypass error prevention strategies, such as the “five rights of medication administration” and “time-out.” This is where autonomous nursing practice will make a huge impact to protect patients. Each healthcare provider has a responsibility to ensure safe patient care. Everyone from the patient to physician needs to feel empowered to speak-up when they observe potentially dangerous situations. It isn’t always easy to speak-up, and it can be intimidating. However, speaking up at the time an error or safety concern is identified will save someone’s life. Seven categories of conversations have been identified as difficult but essential for those in healthcare to master. They are: • Broken rules • Mistakes • Lack of support • Incompetence
• Poor teamwork • Disrespect • Micromanagement3
any of us in healthcare have personally experienced making an M error or observed an unsafe practice as it occurred. Think about the parents, partners, significant others, children, friends…that could have been saved. These errors are now becoming more public, such
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as those involving Josie King, Dana Farber Institute, and the twins of Dennis Quaid. Often time, staff experiencing an error will have an overwhelming sense of guilt. The healthcare professional committing the error can be described as the “second victim”. Our systems and processes must be improved to protect not only the patient, but to prevent the emotional toll suffered by someone who made an error. Kimberly Hiatt, RN, a nurse in the NICU of a Seattle hospital, committed suicide on April 3, 2011 over the guilt of unintentionally overdosing an infant. “The suicide of a Seattle nurse who accidentally gave an infant a fatal overdose last year has closed an investigation but opened wounds for her friends and family members, as they struggle to comprehend a second tragedy.4 This is a wake-up call for the anguish and devastation felt by individuals who have committed errors. We cannot afford to be silent. ____________ 1 Institute of Medicine (2000). To Err Is Human: Building A Safer Health System. Washington, DC: National Academies Press. 2 Patient Safety First (2009), The “How to Guide” for Implementing Human Factors in Healthcare. 3 American Association of Critical Care Nurses, VitalSmarts™, & Crucial Conversations® (2005). Silence Kills. 4 http://seattletimes.nwsource.com/html/localnews/2014830569_nurse21m.html
The First New Graduate Nurse Residency Projects By: Kristy Gorman, MS, RN, OCN, Clinical Practice and Education Specialist On May 12, 2011, the very first New Graduate Nurse Cohort group celebrated the completion of their residency program. The celebration involved the presentation of their unit-based evidence-based practice (EBP) and quality improvement projects. There were a total of 64 new graduates. Each of the Nurse Residents received a presentation certificate and a UHC/AACN Nurse Residency Program™ pin. (And let’s not forget to mention the cupcakes!) The University of Maryland Medical Center is part of the University Healthsystem Consortium/American Association of Colleges of Nursing (UHC/AACN) Nurse Residency Program. The Nurse Residency is a one-year support program designed to ease the transition for new graduate nurses into professional nursing practice. The curriculum focuses on leadership, patient outcomes, and the professional role. During the residency cohort sessions, it is emphasized that evidence-based practice is the combination of the best available research with clinical expertise and patient considerations. Evidencebased practice empowers our nurses to make a difference, while driving improved patient outcomes. Mike Mirzai, RN, a nurse resident from the 3D Telemetry unit states, “Completing this project really gave me a clear view of how committed UMMC is to both patient safety and the development of new team members.” The nurse resident projects included topics on patient safety, such as infection prevention, fall prevention, fever management, patient mobilization, achieving patient goals, preventing post-surgical complications, and delirium prevention. Other topics addressed hospital
Jennifer Eppoliti, BSN, RN and Katherine Frey, BSN, RN, Labor and Delivery, presenting the topic, “High-dose vs. low-dose oxytocin administration protocols in laboring women”.
standards and policies, including administration set changes, medication reconciliation, multi-disciplinary team communication, bedside reporting, implementing change, and central line care standards. Congratulations to the nurse residents who put a lot of time and effort into researching the evidence for best practice. Thank you to the preceptors, unit leaders, and mentors who made a significant impact by ensuring a rich and rewarding experience for the nurse residents.
Five Infection Prevention Practices That Matter By: Michael Anne Preas, RN, BSN, CIC
Hand Hygiene • Perform hand hygiene upon room entry and exit regardless of glove use. • Remember that you pick up transient bacteria on your hands every time you touch surfaces or place your hands in your pockets, etc. Hand hygiene protects patients from these hitchhikers. • Please routinely check and exchange empty alcohol sanitizer bottles. Isolation Patients and Transmission-based Precautions • When patients are in isolation remember: 1. Isolation signs should be visible to all those entering the room. 2. Perform hand hygiene before donning personal protective equipment (PPE). 3. Gown should be properly tied in the back and mask should be worn over the nose. 4. All PPE is to be removed in the room upon exit; perform hand hygiene after removing the PPE. • If traveling with a patient on isolation, after taking patient to their destination, remove PPE and perform hand hygiene. • After discharge, isolation signs should remain in place until the room has been cleaned. Important Points Regarding Airborne Isolation • When entering a patient’s room in Airborne Isolation, all staff, students, and providers must don the reusable or disposable particulate respirator for which they were fit tested.
• If the correct mask is not available, please don a PAPR prior to entering the patient’s room. Equipment Cleaning • When possible, return soiled equipment to Clinical Equipment Distribution (CED) for appropriate cleaning and processing. • Any equipment not returned to CED must be cleaned between patient use. • All equipment not in a patient room must be tagged as follows: Green = Clean Red = Soiled Brown = Enhanced Contact (i.e. used in care of patient with C. difficile) • Soiled equipment should be held in soiled utility until pick-up. Know Your Disinfectants • OXIVIR - hydrogen peroxide surface disinfectant One minute contact time; except for TB where contact time is five (5) minutes. • DISPATCH - bleach Five (5) minute contact time. This is used for cleaning equipment in rooms of patients on Enhanced Precautions. • All surfaces need to remain wet for the minimum required time to ensure effectiveness. Reapply as needed to ensure adequate coverage.
UMMC Nurses Organize Community Health Fair The theme of UMMC’s celebration of Nurses Week 2011 was “Nurses Driving Change: In the Hospital…In the Community…Across the World.” UMMC nurses chose to take this year’s theme to heart and make an impact on the surrounding community by holding a health fair. Vickey Sipes, BSN, RN, OCN, SCN I, BMT Unit, was the visionary and stated, “I have always wanted UMMC nurses to host an event that gave back to our community.” The event was held on Monday, May 9 in Lexington Market from 11a.m. to 3 p.m. Over 100 healthcare professionals volunteered during the four hour event that provided educational materials and offered blood pressure screenings. There were twenty tables with information on nutrition, diabetes, accident and violence prevention, organ donation, child safety, HIV/AIDS education, and many other healthcare topics pertinent to our community. An estimated 500 visitors attended the event to gain valuable information about their current health and methods to achieve a healthier future.
While UMMC’s Community Outreach programs offer several health fairs each year, this event was organized and staffed by UMMC nurses. Vickey and Anne Naunton, MS, RN, Professional Development Coordinator, recruited volunteers from the Medical Center. Tori Walker, MS, PHR, Professional Development Coordinator, provided logistical and operational support, along with Special Project Coordinators, Rachel Hercenberg, BS, Erica Bergstein, BS, and Lauren Davis, BS. Special thanks to Darlene Hudson, Operations Manager, Lexington Market, who worked closely with the planning team to organize this event. Those staffing the health fair received very favorable comments directly from the Baltimore community. In addition, the Medical Center volunteers completed an evaluation of the event, and these results were also very positive. With the feedback from the community and the volunteers, a 2012 health fair is already in the planning stages.
News & Views
Honorable Mention 2011 ANCC Magnet Conference Abstracts Congratulations to the following individuals that had posters accepted for the 2011 ANCC Magnet conference held in Baltimore this year from October 4th to 6th at the Baltimore Convention Center. Only about 6 percent of the overall abstracts submitted for podium presentation or posters are accepted by the ANCC for their annual conference. This is a significant achievement that three posters from UMMC are on the prestigious list. Susanne Anderson, MS, ACNP-BS, CCRN, Professional Development Coordinator, Ariel de Vera, BSN, RN, CCRN, SCNII, MICU, & Ronetta Lambert, MS, RN, Nurse Manager, Medicine • A Nurse-driven Initiative to Address Patient Care Order Management Issues Associated With CPOE Joan McFadden-Cain, BSN, RN, Nurse Manager UHC, Ambulatory • A Nurses’ Initiative to Improve Population Health Through Timely Colorectal Cancer Screening Greg Raymond, MS, MBA, RN, Director of Nursing, Anne Naunton, MS, RN, Professional Development Coordinator, and Edward Bennett, Director Web Strategy • Social Media Guidelines: Protecting the Nurse-Patient Relationship Lisa Rowen, DNSc, RN, FAAN, Sr. VP and CNO Dr. Rowen was the 2011 recipient of the Nurse.com (Nursing Spectrum) Nursing Excellence Awards in the category of Advancing and Leading the Profession. She was chosen from a group of impressive and accomplished nurse leader nominees from the DC, Maryland, and Virginia region. As the winner in this category, Dr. Rowen will be considered as a finalist for the national award that will be announced later this year.
A Farewell to Karen Johnson, PhD, RN, Director of Nursing Research and Evidence-Based Practice Dr. Johnson has moved to Phoenix, Arizona with her family, as her husband has accepted a promotional position and her daughter attends a university in that area. We will dearly miss Dr. Johnson for her many talents and knowledge, contributions Cindy Rew, BSN, RN & Dr. Karen Johnson to nursing and patient care services, and for being such an outstanding colleague and friend. In addition to her remarkable career history that included UMMC and the University of Maryland School of Nursing, Dr. Johnson was a critical team member that was responsible for the submission of the 2009 UMMC Magnet written submission. As Director of Nursing Research and Evidence Based Practice (EBP), Dr. Johnson provided leadership in the development and implementation of a program to address both areas. She built the infrastructure and processes to support nurses to conduct research and use EBP methods to optimize patient care outcomes. As a result, we have an extensive research and EBP portfolio, key to our designation as a Magnet organization. She also developed and published an EBP infrastructure assessment template that is used nationally. In her role, Dr. Johnson mentored 21 research projects involving more than 120 nurses. Her mentoring also resulted in the publication of 41 manuscripts and 104 abstracts accepted at national conferences.
Let’s Get Certified … A Nurse’s Perspective By: Cathy Zei, BSN, RN, CCRN, SCNI I took the CCRN test on January 28, 2011 and I passed! I made quite a big deal out of it. This was one of my goals for a long time, and I finally did it. I was so happy to pass the test and really learned so much during my review class and studying. I want to encourage all of you to think about preparing and sitting for the exam. The test you will take for the IMC is the PCCN, the Progressive Care Certification. I really concentrated my studying over a 1½ week period. I used the materials from a review course, plus the book “Pass CCRN.” I think that using both was really helpful. The book has a CD with test questions. The questions are by systems, and the book includes a comprehensive test. The comprehensive practice test was helpful because it helped to identify focus areas where my knowledge was weaker. At one point, after almost 20 years working in the MICU, I thought
I could just sit for the test and pass it. After this experience, I know that would not be possible. In caring for patients, I didn’t always consider the rationales for patient care. The preparation for the certification exam solidified the practice of an ICU nurse with all of the required knowledge. So, why get certified? AACN states that “Certification is the process by which a non-government agency validates, based upon predetermined standards, an individual nurse’s qualifications for practice in a defined functional or clinical area of nursing. Nursing certification recognizes knowledge, skills, abilities, and experience in areas beyond the scope of the RN licensure.” This translates to the bedside, specifically to our patients and families, where certified nurses have the opportunity to improve the quality of care provided. In addition, at the Medical Center, the yearly amount of money for continuing education increases to $1000.00 for certified nurses. JULY-SEPTEMBER 2011
The Pediatric Asthma Program Drives Quality of Care and Core Measures Compliance By: Keyvan Rafei, MD, MBA, Former Division Head, Pediatric Emergency Medicine; Anna Marie R. Moko, MBA, RN, BSN, Quality Measure Coordinator The Pediatric Asthma Program at the University of Maryland Children’s Hospital is a unique evidence-based care approach that encompasses medical treatment, patient education, and discharge planning. This multi-disciplinary program has been awarded three consecutive Joint Commission certifications for Pediatric Asthma disease specific care and has been responsible for outstanding compliance rates with Children’s Asthma Care. Children’s Asthma Care comprises of three measure sets: 1. Administration of Relievers during hospitalization 2. Administration of Systemic Corticosteroid during hospitalization 3. Home Management Plan of Care (HMPC) that is separate, patient specific, and includes five required data elements. Children’s Asthma Care data has been submitted to the Maryland Health Care Commission (MHCC) since January 2009. The administration of relievers and costicosteroid during hospitalization has been a success from the start. This can be attributed to the multi-disciplinary approach, evidence-based foundation, and a focused metrics-driven process. The Home Management Plan of Care (HMPC) presented the most challenge. Asthma education which includes an action plan, triggers, use of controllers and relievers, as well as follow-up appointment, was given to the patients/caregivers on separate forms. The HMPC measure requires that all mandatory elements be in one separate, patient specific form. The day after discharge review of all asthma patients, with a real time follow-up reminder to residents/fellows by the Director of the program is the most productive initiative after Information Technology assisted in the implementation of the asthma depart process. The HMPC data improved from 50% in January 2009 to 100% in May 2011. The Pediatric Asthma program encompasses the care of children with asthma in the Emergency Department, inpatient units, and the outpatient setting. By employing common documentation tools, education materials and treatment principles, the program promotes a collaborative and coordinated approach among the various patient care settings. Throughout the hospital, patient care coordination is further enhanced by the multidisciplinary bedside asthma flowsheet. This multidisciplinary communication tool is used to monitor treatment response and ensure discharge readiness as reflected in improved respiratory status and completed patient education.
News & Views
The “Patient-Centered Respiratory Care Protocol” that is employed by the inpatient physicians and respiratory therapists, is another unique element that promotes a streamlined approach to the care of patients with asthma. This guided bronchodilator weaning regimen is initiated by pediatric inpatient physicians and administered by specifically trained respiratory therapists. The program includes a detailed description of indications and contraindications to enrollment, and is centered on the “Clinical Asthma Assessment Score”. The “Asthma Medication Weaning Ladder” outlines the process for weaning a patient’s bronchodilator treatments based on the patient’s interval asthma severity. The pediatric respiratory therapy coordinator is responsible for educating participating respiratory therapists for this program. The “Asthma Protocol Exam” is used to assure competency. Throughout the hospital, asthma education is accomplished in a collaborative fashion by pediatric physicians, nurses, and respiratory therapists using the “123’s of Asthma” booklet. This tool was specifically developed by the Pediatric Asthma Steering Committee to address the educational needs of our patient population. The “123” designation refers to the three educational modules that address basic principles of asthma, identification and avoidance of triggers, and principles of asthma management. The modules are designed to be taught in sequence and with repetition to maximize understanding and retention. A complementary multimedia computer based version of the “123’s of Asthma” is also used to provide the same asthma education in an interactive and entertaining fashion. Long-term asthma management and outpatient care coordination is accomplished using the Asthma Action Plan. This stepwise outpatient treatment guide is developed and tailored for each individual patient. It serves as a tool to promote care coordination and communication with the outpatient primary care provider. A focused metrics driven approach has been responsible for the long term success of this program. A dedicated group of nurses, respiratory therapists, quality improvement coordinators, and physicians make up the Pediatric Asthma Steering Committee that oversees this program and selects the measures by which success will be measured. A combination of real time compliance tracking, monthly summary review, and provider specific feedback, optimizes bedside care and Joint Commission compliance.
Clinical Practice Update
We Discover Journal Club Hot Topics – HIV Testing By: Luiza Lima, MS, RN, Professional Development Coordinator Journal Club Hot Topics provides highlights and pertinent content from the discussion of the article chosen for a recent journal club. Corey Farrell, MPH, RN, ACRN, SCN II and Katrice Royster, MS, RN, OCN, SCN I were the facilitators. The article was a research study on the use of a HIV testing to screen patients as part of routine medical care. The role of the nurse in facilitating early HIV testing was emphasized. Article reference: Siegel, M., Kennedy, L., Rexroth, K., Lankford, M., Turner, M., McKnight, A., Cummins, S., Benator, D., & Kan, V. (2010) “Better but not ideal acceptance of routine inpatient HIV point-of-care testing among veterans in a high prevalence area”. Journal of Acquired Immune Deficiency Syndrome, 55(2), pgs.205-10. Discussion: • Baltimore has the highest incidence of HIV cases in Maryland. • 21% of individuals with undiagnosed HIV produce approximately 50% of new HIV cases. By getting people diagnosed and in care, we can significantly reduce transmission. • OraQuick Advance Rapid HIV test kit is used in the study and at UMMC. It is performed with either oral secretions or whole blood. UMMC is currently offering oral rapid HIV testing to patients in the Adult ED and some units by certified testers. • The test kit has a high sensitivity and specificity. • Nurses play a very large role in educating patients on HIV and preventing transmission. Nurses should talk with patients about HIV testing and ask if patients want to be tested. A prescriber order is required. JULY-SEPTEMBER 2011
University of Maryland Medical Center 22 South Greene Street Baltimore, MD 21201 www.umm.edu
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