LOMA LINDA UNIVERSITY HEALTH
NURSING A N N U A L R E P O R T
20 16
LLUHMKTG#MC-155-16/0217/250
TABLE OF CONTENTS Nursing Letters...........................................................................................................2 Who is Loma Linda Nursing?.....................................................................................6 Our Magnet Journey..................................................................................................8 Nursing Practice Model.............................................................................................10 Professional Governance...........................................................................................12 The Loma Linda University Children’s Hospital RN Residency Program..................14 Leadership Residency...............................................................................................16 Interprofessional Initiatives........................................................................................18 Violence Erupts.........................................................................................................20 Director of Nursing Research....................................................................................22 Nursing Evidence-Based Practice and Research Council.........................................24 17th Annual Evidence-Based Practice and Nursing Research Conference................26 Nursing Research and Evidence-Based Practice......................................................28 An Evidence-Based Doctor of Nursing Practice Project...........................................32 Leading Us Into the Future........................................................................................34
Loma Linda University Medical Center
Reflections on 2016 Over this past year we have had an unusual amount of change. We have strengthened our leadership structure so that our nursing staff see and feel the support they need to address the complex issues in today’s patient care environment. In addition, we have provided educational opportunities for these new leaders so that they have the tools they need to be successful and to empower our nursing staff. During 2016, we implemented our strategic plan. We focused on new evidence-based nursing practices, engaged staff in professional governance and focused on improving the quality of care. Additionally, we have involved nurses in a variety of initiatives to engage our staff and search for ways to improve clinical outcomes. Some of our accomplishments are:
• Welcomed 137 new nurses to the Loma Linda University Medical Center (LLUMC) nursing team. • Recognized 12 DAISY award honorees and 148 nominees. • Participated in the interprofessional, organization-wide initiatives on heart failure and sepsis. In heart failure, we have helped streamline the experience for patients and providers so that we are able to reduce readmission, decrease length of stay and improve outcomes. • Initiated the process to achieve status as a Comprehensive Stroke Center. • Successfully completed a Joint Commission reaccreditation survey. • Instituted a process through the float clock to improve patient flow. • Started our journey towards achieving Magnet status by hiring a Magnet coordinator. • Eighty-one nurses are actively participating in the RN-BSN program developed in collaboration with the Loma Linda University School of Nursing. • Collaborated with the Loma Linda University School of Nursing in the development and implementation of a Nursing Leadership Certification Program. • Created a pre-licensure student nurse assistive personnel (SNAP) work program in collaboration with Loma Linda University School of Nursing. I am grateful for each of you and for the part you have played in helping us achieve our goals. I am especially proud of the way that you have embraced and implemented new ideas and evidence based practices. To paraphrase the words of Florence Nightingale, nursing is a noble calling but it is up to us nurses to make it noble. Thank you for continuing to seek ways to improve nursing and our patients’ outcomes. Sincerely,
Jan Kroetz, MN, RN, NE-BC Chief Nursing Officer Loma Linda University Medical Center
Loma Linda University Children’s Hospital
Dear Colleagues and Friends, I find myself resonating with the words of Anne Frank, “How wonderful it is that nobody need wait a single moment before starting to improve the world.” Nursing is both challenging and rewarding and two of the most important traits for nurses are compassion and a desire to make a difference. On a daily basis you deal with difficult situations and difficult questions which was poignantly brought home to me recently. One of our young patients was reading an art book with his nurse and this is what I overheard. Child, “What is that picture supposed to be?” Nurse, “Well I think it is supposed to be a tiger, but it is called abstract art.” Child, “Well why isn’t it a tiger?” We ask that question almost daily and sometimes receive the same sort of answer as we look to enhance the services we provide with limited resources. Yet as I look back over this past year we have accomplished much.
“Cure sometimes. Treat often. Comfort always,” Hippocrates said. Please contact me with your thoughts, ideas and creativity as we work together to advance nursing in the Children’s Hospital. You are the breath of this organization and I want to empower you to achieve excellence each and every day! Sincerely,
Helen Staples-Evans, DNP, NE-BC Chief Nursing Officer Loma Linda University Children’s Hospital
NURSING ANNUAL REPORT | 2015 - 2016 3
• On Sunday, May 22, 2016, we broke ground on our new hospital towers, the official start of a journey that will actualize Vision 2020. This space will provide private rooms to ensure a healing environment for children and families and prominently display our position as the beacon of hope for sick children in the Inland Empire. • Twenty-two of our nurses are actively participating in the RN-BS program set up with Loma Linda School of Nursing. Many more are in other nursing programs pursuing graduate nursing education at the masters and doctoral level. All are moving forward with a focus on excellence and I look forward to their continued commitment to our children and families. Many of our successes as an institution are a result of student projects that have risen from these educational endeavors. • We have initiated multidisciplinary pathways and have joined the Children’s Hospital Association collaborative with at least 40 other children’s hospitals to develop initiatives related to sepsis. We embark on this mission with a lofty but important goal of decreasing mortality and hospital acquired sepsis by 75%. I am excited to see the results we can achieve when we combine collaboration, evidence-based practices and the evaluation of data from these interventions with our dedicated and excellent staff at Loma Linda University Children’s Hospital (LLUCH). • Our journey to Magnet designation has begun with the formation of professional governance councils. These councils are active on 80% of our units and working toward positive results in areas related to sibling visitation, floating practices and quiet time. • Several departments have sent teams to process improvement green belt training. These teams are identifying frustrations and inefficiencies with everyday workflows. Through the use of these tools and resources we are positively affecting change and improving the care delivered to children and families at LLUCH. I am honored to work with each member of our staff as we live our mission.
Loma Linda University Behavioral Medicine Center
The Loma Linda University Behavioral Medicine Center (LLUBMC) has implemented several galvanizing initiatives. Some of the 2016 highlights were:
• Initiation of Professional Governance Councils. • Use of a bed board to facilitate patient throughput resulting in increased admission rates and census. • Successful implementation of aromatherapy in Geriatrics for fall prevention resulted in decreased fall rates. • The implementation of Structured Interprofessional Bedside Rounds (SIBR) on all the inpatient units. • Implemented best practices resulting in the significant reduction in the use of restraints to near zero. • Increased nursing staff engagement to the 68th percentile on the employee engagement index. • Increased the number of RNs participating in the RN-BS program with Loma Linda School of Nursing. Currently 17% of our nursing staff are back in school and we project that by 2018, 82% of our nurses will have their BSN. Sincerely, Norie Bencito, RN, MS Chief Patient Care Director Loma Linda University Behavioral Medicine Center
Loma Linda University Medical Center – Murrieta
Loma Linda University Medical Center – Murrieta (LLUMC – M) blends the latest technology with hightouch care in a calm, healing environment. As we moved through 2016, we celebrated the following milestones:
• Our five year anniversary of providing patient care throughout Southwestern Riverside County. • Becoming the 2nd largest STEMI receiving center for Riverside County. • Achieving Primary Stroke Certifiication as every RN has been trained by our stroke nurse navigator. • Looking forward to the 3rd quarter of 2017 when we are scheduled to open our 6-bed NICU. Sincerely, Linda Soubirous, RN, DNP Chief Nursing Officer Loma Linda University Medical Center – Murrieta
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Who is Loma Linda Nursing?
We Work in Loma Linda University Medical Center
6
Loma Linda University Children’s Hospital Loma Linda University Behavioral Medicine Center Loma Linda University Medical Center East Campus
Hospitals
Loma Linda University Surgical Hospital Loma Linda University Medical Center – Murrieta
34 Operating Rooms 11 5 5 7 6
We Saw
77,614
Loma Linda University Medical Center
patients in 2016 through our emergency department
Loma Linda University Children’s Hospital
47,932
Loma Linda University Medical Center East Campus
adults
AND
Loma Linda University Surgical Hospital
29,682
Loma Linda University Medical Center – Murrieta
pediatric
We Have
1,238 RNs with BSN
171
RNs with MS
5
RNs with PhD or DNP
Age Group
Loma Linda University Children’s Hospital
Loma Linda University Medical Center
Grand Total
<24
10
41
51
24-35
410
668
1078
36-50
289
463
752
51-65
188
273
461
Over 65
22
39
61
Grand Total
919
1484
2403
Data provided by Loma Linda University Shared Services Human Resources
This data includes the age groups of all CN-B through CN-Ds and only clinical nurses. This number will not match the education table above.
Loma Linda University Childrenâ&#x20AC;&#x2122;s Hospital
Loma Linda University Medical Center
Grand Total
Two or More
2.3%
1.9%
2.0%
American Indian or Alaskan Native
0.3%
0.4%
0.4%
Asian
26.1%
32.3%
30.0%
Black or African American
3.5%
5.3%
4.6%
Hispanic or Latino
21.3%
21.5%
21.4%
Native Hawaiian or Pacific Islander
0.3%
0.6%
0.5%
White
46.1%
38.0%
41.1%
Grand Total
100.0%
100.0%
100.0%
Data provided by Loma Linda University Shared Services Human Resources
We Volunteer
We volunteer internationally to support health providers and improve outcomes.
6 768
RNs who have gone on approved mission trips and the countries involved with approximately volunteer hours.
NURSING ANNUAL REPORT | 2015 - 2016 7
Ethnic Group
Our Magnet Journey The Magnet journey ensures huge strides not just for the profession of nursing, but for enhanced patient care at Loma Linda. We are beginning to weave the American Nurses Credentialing Center (ANCC) Magnet Model components into our culture to exemplify excellence in nursing structural empowerment, exemplary professional practice, new knowledge, innovation and improvements and transformational leadership. This journey will allow us to create an even higher level of professionalism for nurses in our organization. Some of our goals for this journey include: increasing nursing retention rates, professional opportunities, shared decision making and a commitment to relationship-based care through exemplary practice and positive outcomes. In nursing, like all of health care, it is never enough to rest on one’s laurels. Our commitment to continuous quality improvement allows us to celebrate our successes and continue to strive to provide optimal care for our patients and families. The Magnet journey for Loma Linda University Health (LLUH) is progressing with a goal to be surveyed before the new hospital opens. The culmination of the Magnet journey will affirm LLUH excellence in nursing. In initiating the journey, educational sessions have been provided to the leadership at leadership and management principles in nursing leadership, nursing excellence forum and in one-on-one meetings. Recently, Joint Commission validated that the adult services has reached best practice levels in multiple areas of intravenous drug titration, care plans, dialysis, among others. During the separation of the children’s hospital and adult services, the surveyors identified several best practices in our LLUCH including the Structured Interdisciplinary Bedside Rounds (SIBR) rounds. The recognition of our staff as being excellent, caring nurses is in progress. Walking through the units, one can see recipients of awards, such as employee of the month, daisy and good Samaritan awards and other nurses’ achievements.
Community outreach is an important part of Magnet designation. In exploring Magnet designation requirements, we have self-scheduling (API), self-evaluation and peer evaluation (performance manager) in place. We are currently assisting more nurses to obtain a bachelor’s degree in nursing. Additionally we are assisting staff to understand the benefits of having the additional knowledge that comes from
the inclusion of psychiatric nursing, community health nursing, use of statistics, research and leadership training that is part of the curriculum. This demonstrates how the bachelor’s degree in nursing will benefit nursing practice and the quality of patient care. Obtaining a bachelor degree in nursing is supported by both the bridge program and tuition support from LLUH. Another aspect of the journey is the encouragement of nurses to validate their knowledge base by obtaining national certifications in practice specialties. To support this endeavor upon obtaining national certification, funding for the cost of taking the test and maintenance of the certification is available on a yearly basis. Community outreach is an important part of Magnet designation. We have nurses who volunteer at various community walk-a-thons such as a LLUCH Walk to Remember and Loma Linda University Cancer Center (LLUCC) Believe Walk.
the units, one can find nurses excited about professional governance and having their voices heard. They appreciate the interdisciplinary rounds that values their clinical input and the resulting understanding of the plan of care for their patients. Culture starts from the top, but the continuance of it comes from the ground up. We are continuing to engage staff during walking rounds, speaking one-to-one with nurses, helping them understand Magnet designation and what it means, how it focuses on the clinical nurse and care of the patient. We are increasing the visibility of the value of nursesâ&#x20AC;&#x2122; exceptional care, discharge planning and teaching how that relates to reductions in readmission rates, length of stay, increases in patient and nurse satisfaction scores and improvement in other quality measures. Magnet is a journey that is ongoing for the growth and development of our staff with increased patient satisfaction and outcomes for our patients.
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Staff can also be found volunteering at health fairs, hospital days and other community outreach. Examples of other types of community outreach include: nurses from the Total Care Birth Center providing training for OB nurses from Ridgecrest Hospital; and providing clinical sites for nursing students from multiple schools in pediatrics (California Baptist, San Bernardino Valley College, Weimar, Western, Pacific Union College, Azusa Pacific and our own school of nursing). We also provide a clinical site for graduate nurses working on their DNP projects or PhD dissertations. We are valued within the community for the education that we provide. As part of the international community we have birthing classes for mothers and nurses traveling to other countries to help teach and train nurses in best practices. We have good nurses and we are working hard to empower them, encourage their confidence in themselves and the quality of their work. We are working to help them realize the professional aspects of nursing. Walking through
Nursing Practice Model
Our Professional Governance Councils, nursing leadership and clinical staff have adopted the Duffy Quality of Care Model for our nursing practice model at Loma Linda. According to Duffy (2009), caring professional practice requires:
1. Knowledge of the caring factors and relationships among patients and caregivers, the health care team and the community. 2. Skills, which can be both behaviors and competencies. 3. Intentions, which are the attitudes and beliefs that lead to choices. 4. Time, with a primary focus on relationships; this involves the integration of “being” and “doing.” The role of the nurse in this model is to engage in caring relationships that lead to feeling “cared for.” The caring relationships include caring for self, caring for patients and caregivers and caring for community. Feeling “cared for” assists patients and caregivers in improving short- and long-term outcomes, including those that are nurse-sensitive. Collaborative relationships describe nursing behaviors with interprofessional team members that help patients and caregivers understand how to confront, learn and think about their health and illness. This gives patients information they need to be better partners in decision making regarding their care and treatment.
Independent relationships refers to honoring the worth of humans through unconditional acceptance, kind and careful handling of the human body and recognition of rights and responsibilities. A nurse’s encouraging manner demonstrates caring through demeanor or attitude. Messages of support, positive thoughts and feelings and openness to the feelings of others are what allows patients to feel cared for. Some aspects that are important include:
• An appreciation for the diversity of our patients and knowing what is important to patients, including distinctive sociocultural connections associated with their experiences. Nurses use those features that are important to them in the provision of care. • The healing environment of our hospitals which are focused on holistic care and safety. These aspects are championed by our professional governance councils and our evidence-based practice teams. • Our mission is “to continue the teaching and healing ministry of Jesus Christ,” as we care for patients, families, employees and health care providers. This mission is reflected in the quality-caring model.
The Quality-Caring Model© provides a framework for nursing that resonates with professional nurses and is readily applicable in their daily practice.
The Quality-Caring Model STRUCTURE (Casual Past)
PROCESS
PARTICIPANTS Provider
Phenomenal Field Descriptors Unique Life Experiences Attitudes and Behaviors
Relationship Centered Independent Relationships
Patient/Family-nurse (Discipline-specific)
Patient/Family
Phenomenal Field Descriptors Unique Life Experiences Severity of Illness Comorbidities
System
Phenomenal Field Descriptors Staff Mix/Workload Organizational Culture Resources
Collaborative Relationships
Health Care Team-Nurse (Multidisciplinary)
Professional Encounters
OUTCOMES (Future)
TERMINAL OUTCOMES Provider
Satisfaction Personal Growth
Patient
QOL Safety Disease-specific Satisfaction Knowledge
System
Utilization Resource Consumption Readmission Costs LOS
INTERMEDIATE OUTCOMES FEEL “CARED-FOR”
The Quality-Caring Model© provides a framework for nursing that resonates with professional nurses and is readily applicable in their daily practice. Duffy, J.R. (2009). Quality Caring in Nursing: Applying Theory to Clinical Practice, Education and Leadership. Springer Publishing Company: New York.
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Professional Governance
Allison Ong, MSN, RN, CCRN Director of Patient Placement and Transfer Center
Professional governance is a collaborative governance structure that gives professionals, such as nurses, a voice regarding issues that affect their practice. “Professional governance is a shared decision-making structure where the point-of-service staff members are involved in making decisions about clinical practice,” Johns explains. “We started by reviewing the issues they felt were impacting their ability to provide the best patient care on the floor. Primary nursing topped the list.” Kimberly Johns, MSN, is a clinical nurse specialist on unit 4800, the pediatric hematology and oncology wing of LLUCH. In 2016, 20 professional governance councils active among the LLUH hospitals. These include nine in LLUCH, 12 in LLUMC and one at LLUBMC. The departments with an active professional governance council include: LLUCH NICU, TCBC, 4200, 4800, Acute Care Pediatrics, 5700, 5800 Cardiac and 5800 Step Down. In the adult services units at the Loma Linda University Medical Center East Campus (LLUMCEC) and LLUMC: 1300, 4100, 4700 Adult Acute Medicine, 7100, 7200, 7300, 8200, 9200 and Critical Care System Transport. We have also initiated professional governance councils in home health. Projects that the councils have engaged include improving communication, primary care nursing, employee recognition, team huddles, patient satisfaction and clinical practice quality improvement. Professional governance has seen many successes. Staff feel that they have an opportunity to positively impact the quality of care provided to their patients. They bring their expertise as front-line staff to the table and are eager to share how to improve processes.
Staff feel that they have an opportunity to positively impact the quality of care provided to their patients.
e Man Who Mak le o T Professional Governance Design Team
To Impact Quality Excellence
Teamwork
Integrity
ctice Pra
Qua l i
ty a
nd
Sa
fet
ssional Develop Profe me
y and Procedures Polic
y
C
li
al n ic
Service Line Councils
le Who
nes
s
nt
NURSING ANNUAL REPORT | 2015 - 2016 13
Coordinating Committee
i tm e
nt, Retention
a nd R eco gn
i ti
on
s s i on
c ru
mpa
Re
Co
To Impact People
The Loma Linda University Childrenâ&#x20AC;&#x2122;s Hospital RN Residency Program The LLUCH RN residency program was created in 2002. Originally, the program was moderated by Versant. The Versant program curriculum is the gold standard for newly graduated nurses entering medical establishments. In 2011, we branched off from Versant and created a tailored version of the program that was more precise to the principles and mission of LLUCH. The RN residency consists of two cohorts per year beginning in April and September. The cohorts are 16-weeks in length and RN residents work 36-40 hours a week. The RN residency program provides a comprehensive education and training that contributes to the transition from the newly graduated registered nurse to a safe, competent and professional partner in health care. The RN residents spend 75% of their time in direct patient care on the unit. During this time, they are under the guidance of a preceptor and practice nursing interventions as a team. By the conclusion of the residency, they are managing their patient responsibilities with minimum assistance. The remaining 25% of the residency time is spent in class for comprehensive learning. While in class they have mentoring sessions, debriefing gatherings and various other curricular activities to assist in their development into an apprised clinician. By the conclusion of the RN Residency, the nurse has become autonomous and simultaneously a well-rounded team player. Each cohort varies in size depending on the specific staffing needs of the hospital and the individual units. The average is 25-44 residents per cohort with the current cohort having 38. Units
that typically participate in the residency program are: Pediatric Intensive Care Unit, Step-Down Intermediate Care Unit, Cardio-Thoracic Intensive Care Unit, Neonatal Intensive Care Unit, Pediatric Hematology/Oncology, Acute Care Pediatrics, Adolescent Acute Care and Total Care Birth Center. The hiring timeline begins with an open application timeframe of 48 hours, once in the spring and again in the summer. Typically, 250-450 applicants are received at each interval. In the most recent hiring, we received 355 applications. Each unit completes its own hiring process of new graduates. Once chosen, the new graduates enter the program as an RN resident. The current cohort will conclude in December. By the end of 2016, 911 registered nurses will have graduated from the LLUCH RN residency program. The RN residency program is very beneficial to the LLUCH. It generates a connection with the new graduate which encourages commitment and retention. The hospital also experiences an overall increase in the job satisfaction scores. It also allows the RN resident to develop and build a strong foundation in the clinical practice leading to a higher level of competency. The RN residency in the recruitment of qualified applicants decreases the unfilled nursing positions by 50%. The LLUCH RN residency program is a significant and necessary component to the operations of the medical establishment.
Truphosa Otianga, DNP, RN Director of Acute Care Pediatrics and Manager RN Residency in Pediatrics
NURSING ANNUAL REPORT | 2015 - 2016 15
Leadership Residency LLUH started a Nursing Leadership Residency program in 2013 to engage baccalaureate prepared nurses with the opportunity to develop leadership and management skills and pursue a career as a future nurse leader at LLUH. This paid, full-time program comprises residency rotations with leaders and mentors across LLUH
Allison Ong, MSN, RN, CCRN Resident 2013-2015 Director of Patient Placement and Transfer Center
Jethrone Role, MSN, RN Resident 2014-2016 Manager of Supplemental Staffing Network
Silvinia Cuizon, BSN, RN Resident 2016-2018
organizations over a two-year period and covers the cost of graduate education. The nurse is given direct opportunities to work with leadership in multiple departments, service lines and disciplines building vital management and professional proficiencies. Many of the residents have transitioned into leadership positions within LLUH.
Truphosa Otianga, DNP, RN Resident 2013-2015 Director of Acute Care Pediatrics and Manager RN Residency in Pediatrics
Holly Yelorda BSN, RN Resident 2014-2016 Magnet Coordinator
Crystal Robinson, BSN, PHN, RN Resident 2016-2018
Post Baccalaureate Certificate in Nursing Administration The Nursing Leadership Certification program was developed beginning in 2014 at the request of LLUH in collaboration with LLUSN. Key drivers in program development included the desire to provide an educational option for registered nurses with a bachelor’s degree in nursing with the following:
1. An opportunity to learn content needed for beginning leadership roles within the work setting for nurse managers. 2. A course that would provide the educational content needed to prepare for the American Nurses Certification Corporation Nurse Executive examination and prepare the nurse to earn the credential of “Board Certified” (BC) nurse executive or manager upon completion of the national exam. 3. Proven academic credit that could be applied to a graduate degree in nursing with a focus in nursing administration. A 12-unit certification program was developed and implemented Fall Quarter 2014. 14 students from both LLUH and LLUCH started the program, with 12 completing all of the required courses. Content for this certification program included nursing leadership: principles and practices; human resource management in health care; health care finance; introduction to quality improvement from a leadership perspective; and an overview of key elements of nursing research and its impact on patient care.
Out of the original group, one has completed her graduate degree and three more are in the process of completing advanced practice degrees in nursing. Positive feedback was received from LLUH, LLUCH and the students involved in this first certification program. Conversations have begun between LLUS, LLUH and LLUCH about offering this program again in the near future.
NURSING ANNUAL REPORT | 2015 - 2016 17
At the end of the academic classes a two-day exam review seminar was held to further prepare the students for taking the national boards.
Interprofessional Initiatives These initiatives resulted in a 10% increase in the scheduling of follow-up appointments for patients, an 18% increase in the documentation of daily weights and slight increases in door to diuretic medication.
Structured Interdisciplinary Bedside Rounds (SIBR)
Sepsis LLUMC and LLUCH nurses participated in the interprofessional task force to address sepsis. In response to the surviving sepsis campaign, the interprofessional task force, which included nurses from the emergency room, clinical units, and home care, evaluated the current approach to sepsis in our institutions and developed an updated protocol for identifying and responding to patients with sepsis. Some of the interventions developed by this team included alerts to help identify patients that present signs and symptoms of possible sepsis and severe sepsis, a new sepsis flag in the electronic medical record to assist nursing leadership identify which patients on their unit are possibly septic and a sepsis review link in the electronic medical record that allows the nurse to easily access the trends in patientâ&#x20AC;&#x2122;s vitals, WBC, bilirubin, creatinine, lactate levels and the current inpatient medication orders. Through team feedback on the sepsis initiative we have been able to refine processes and improve outcomes.
Heart Failure To address and improve our outcomes in patients with heart failure an interprofessional team developed a set of initiatives such as new heart failure order sets, processes to decrease door to diuretic administration time, laboratory results turn around, improvement in the documentation of daily weights and an increase in patient follow-up appointments within seven days of discharge. In addition, the team developed a booklet for patients and families on the management of heart failure from hospital to home.
Structured Interdisciplinary Bedside Rounds (SIBR) provide the validated structure that increases interdisciplinary communication bringing together many care providers involved in the patients care at the bedside, including the patient and family. This interaction with the health care team provides an opportunity for anyone to raise questions and concerns on a level-playing field, one symbol of a strong culture of safety in a hospital. In 2016 SIBR was implemented in both the adult and childrenâ&#x20AC;&#x2122;s hospital units. Through the use of SIBR we will increase efficient, accurate and timely communication for quality health care among interdisciplinary care teams.
Modified Early Warning System (MEWS) In 2016 we initiated the Modified Early Warning System (MEWS) in the acute care nursing units. This tool assists nurses in monitoring patients and can aid in optimizing how quickly a patient experiencing a sudden decline receives clinical care. The MEWS is a physiologic scoring system for bedside assessment patients. Early detection of changes in a patientâ&#x20AC;&#x2122;s condition can make a life-saving difference. Identifying patients at risk for deterioration and cardiopulmonary arrest and providing early intervention has reduced unplanned admissions to the intensive care unit (ICU) and patients suffering cardiac arrests within the units of the hospital.
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Violence Erupts
On December 2, 2015 two assailants with assault rifles opened fire at an office party at a county facility in San Bernardino, leaving 14 dead and 21 wounded. Among those first responders were the medical and nursing staff at LLUMC. The community rallied in support of those at the center of this violence. Los Angeles County-USC Medical Center, Rady Childrenâ&#x20AC;&#x2122;s Hospital in San Diego and UC Irvine Medical Center offered to send staff that day. Local businesses sent food and water to the hospital and pizza deliveries arrived from anonymous emergency nurses from Boston and Texas. Over the weeks that followed, hospital staff and administration received cards and letters from members of the local community and communities across the country. The Medical Center of Aurora in Colorado sent a large banner with more than 100 staff signatures similar to the one they received in the days following the Aurora theater shooting, from the hospital that received victims from the mass shooting at Virginia Tech.
As we proceeded into 2016, more episodes of violence occured across the nation. On June 12, 2016, a shooter killed 49 people and wounded 53 others. In response, our nursing leadership reached out to Florida Hospital with messages of support and food for the staff. Then again on September 17, 2016, a mass stabbing occurred at a central Minnesota mall in St. Cloud, Minnesota. Again we reached out with messages and food to encourage these other medical communities who were in the midst of events we wish no one should have to experience. In dealing with such violent events, it is important that we provide for those in harmâ&#x20AC;&#x2122;s way, those who are first responders and keep the hospitals that care for the victims in our prayers while offering small measures of support that show our thoughts are with them.
NURSING ANNUAL REPORT | 2015 - 2016 21
Among those first responders were the medical and nursing staff at Loma Linda University Medical Center.
Director of Nursing Research We currently have nine evidence-based practice teams throughout our hospitals, in areas including:
• LLUMC surgical and trauma, ICU unit 8100 • LLUMC cardiology services, seventh floor • LLUMC acute care medicine, sixth floor • LLUMC medical ICU unit 4700 • LLUMC vascular access team • LLUMC operating room • Loma Linda University Surgical Hospital (LLUSH) perioperative services • LLUBMC child and adolescent units The LLUCH teams that will be forming early in 2017 will be – Pediatric ICU, Cardiovascular ICU, unit 5800. We will be continuing to expand the evidence-based practice teams throughout LLUCH and adult service lines as we move through 2017. Patti Radovich, PhD, CNS, FCCM Director Nursing Research 2016 has been an exciting year as several of our evidence-based practice teams had abstracts accepted for poster presentations at national nursing conferences. Invitations were extended to our nursing staff to provide a podium presentation at the California Perioperative Nurses Society Annual Conference and to submit a manuscript to the Journal of Perioperative Nursing. Our medical surgical oncology team’s manuscript on prevention of urinary catheter associated infections in the oncology population was accepted for publication in 2017.
In addition, we assisted the Loma Linda University School of Nursing in sponsoring the guest speaker, Dr. Peter Buerhaus, for this year’s Nursing Science Seminar. Dr. Peter Buerhaus is a nurse and healthcare economist, known for his studies and publications focused on the nursing and physician workforces in the United States. He is professor of nursing and director of the Center for Interdisciplinary Health Workforce Studies at Montana State University.
Additionally, we have several nurses who are pursuing graduate nurse degrees as Doctors of Nursing Practice (DNP). These student’s evidencebased change projects have contributed to improvements in the quality of care provided to our patients. Our 17th Evidence-Based Practice and Nursing Research Conference held during nurse recognition week saw the participation of 150 attendees. Keynote speakers Aimee Hoskins from Vanderbilt and Jennifer McDonald from Glendale Adventist energized participants with their presentations.
“We will be continuing to expand the evidence-based practice teams throughout Loma Linda University Children’s Hospital and adult service lines as we move through 2017.”
NURSING ANNUAL REPORT | 2015 - 2016 23
Nursing Evidence-Based Practice and Research Council The nursing research council at LLUH consists of members from pediatric acute care, advanced practice nursing, LLUBMC, case management, quality, staff development, vascular access team, critical care, Loma Linda University School of Nursing and the Loma Linda University Del E. Webb Memorial Library. The council meets the first Thursday of each month. The current members of the council are:
• Patti Radovich, PhD, Chair • Shayne Bigelow-Price, MS • Ellen D’Errico, PhD • Barbara Elson-Hurdle, MS • Sukh Dev Singh Khalsa, DNP, FNP • Karen Lawson, BNS • Ann Mijares, MS • Truphosa Otianga, DNP • Jeannine Sharkey, DNP, FNP • Nelia Wurangian-Caan, MS • Jennifer Newcombe, DNP, PNP • Sarah Capalla, MSN
Front row: Ann Mijares, Nelia Wurangian-Caan Not pictured: Sukh Dev Singh Khalsa, Karen Lawson, Jeannine Sharkey, Sarah Capalla
NURSING ANNUAL REPORT | 2015 - 2016 25
Back row: Patti Radovich, Ellen D'Errico, Barbara Elston-Hurdle, Shayne Bigelow-Price, Truphosa Otianga, Jennifer Newcombe
17th Annual Evidence-Based Practice and Nursing Research Conference The 17th Annual Nursing Research and Evidencebased Practice Conference “Research & Evidencebased Practice: Impact on the Patient Experience,” was held Thursday, May 12, 2016 and attracted 150 attendees and 32 poster presentations. This conference is sponsored by the Nursing Evidencebased Practice & Research Council, LLUH Department of Nursing, LLU School of Nursing, and Sigma Theta Tau Gamma Alpha Chapter. The presentations highlighted the impact evidencebased nursing care has on the patient care experience. Keynote speakers were Aimee Hoskins, BSN, of Vanderbilt University Medical Center, spoke on the topic of “Post-Intensive Care Syndrome (PICS): Strategies to meet the needs of the patient during and after critical illness.” Jennifer McDonald, BA, of Glendale Adventist Medical Center (GAMC) discussed, ”Putting the patient back in the patient experience.”
In the afternoon five nurses from Loma Linda University Health updated attendees on evidencebased practice and research:
• Jennifer Newcombe, DNP, CNS, CPNPPC/AC, discussed “Nurse-driven feeding protocol in pediatric cardiac surgery patients.” • Denise K. Petersen, MSN, CHRN, FNP-BC, talked about “30-day readmission risk in heart failure patients.” • Maria Letts, DNP, FNP, addressed the “Development and implementation of a web-based perioperative interface.” • Michele Wilson, MS, CCNS, CCRN, reported on how “PICU structured interdisciplinary bedside rounds impacts communication and nursing and family satisfaction.” • Julia Pusztai, PhD, RN, shared her observations on “Listening to the oldestold: varied meanings of spirituality in the experience of aging.”
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Nursing Research and Evidence-Based Practice Nursing Research Study LLUMC and Childrenâ&#x20AC;&#x2122;s Hospital Vascular Access Team is participating in a research study as a FDA testing site for the vascular positioning system. This study will examine the use of the Vascular Positioning system in children and the potentials for the elimination of chest x-rays in pediatrics for position verification. Currently this device is only approved to eliminate chest x-ray in adults.
Evidence-Based Practice Team Projects The evidence-based practice team projects involve a wide variety of topics. Some examples of the projects in progress include:
Unit 9200 and 9300 members Jennifer Blackey, Carol Nielsen Not pictured: Monica Paredes, Brittney Jonas, Amy Paluzzi, Sara Allen, Charis Jones, Josette Raguero Clinical bedside nursing staff and hospital CAUTI task force. This team developed a nurse driven protocol for the insertion, care and maintenance of urinary catheters that was adopted by the entire adult hospital.
Home care team members Denise Petersen, Sandra Lay, Susan Johnsen, Nancy Moody Home care nurses, LLUMC seventh floor nursing staff and cardiology clinic nurse practitioner. This project involves the use of Teach-back in Heart Failure Patients and has found increased engagement of patients in their care, patients demonstrating increased self-awareness and knowledge of their HF zones and their emotional states.
Unit 4700 MICU team members Allison Bell, Matthew Medina Clinical bedside nursing staff, the nutritional team, respiratory care providers and MICU physicians. This team is using a nurse driven protocol in the medical intensive care unit is looking to reduce the amount of time patients are without nutrition due to feeding interruptions.
Sixth floor team members Cinthia Ortiz, Kelly Wolff, Amanda Edwards, Jewel Role, Myra Sanchez, Trisha Cardona, Novi Sitanggang Clinical bedside nursing staff, FIT team members, ED nursing and Patient Safety and Reliability. The team is looking to increase prevention and reduce pressure ulcers in patients admitted to the medicine service from the Emergency Department. The team implemented improved documentation [Braden subscale prevention interventions embedded] and increased assessment/prevention interventions in the ED.
Johnathan Avilar, Tracey-Anne Anacleto, Stephanie Ferrero, Jaye Galiza, Casey King, Antora Majumder, Megan Lang Front row: Ellyne Jan Wills, Gale Duckworth, Monique Yoeliko Not pictured: Penny Amornvut, Christopher Fjellstrom, Steve Watson, Cameron King, Tony Ingkiriwant, Leo Castelo Clinical bedside staff from the cardiology units. This team is evaluating and comparing two fall assessment tools and interventions for fall prevention in the adult patient population.
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Seventh floor team members
Loma Linda Medical Center East Campus acute rehabilitation team members Cydney Love, Chris Marlett, Delia Linch, Erica Levy, Veronika Laketau Not pictured: Pamela Albaugh, Kelsea Chun Clinical bedside nursing staff, educators and leadership. This team implemented evidence-based practices in fall reduction in patients who have had a stroke, traumatic brain injury or amputation and are admitted to the acute rehabilitation unit.
Loma Linda University Surgical Hospital perianesthesia team members Andrea Mason, Amelia Tiefenthaler, Stephanie Keeth Not pictured: Maureen Macatula, Trisha Arellano, Danya Egger Preoperative, post anesthesia care nurses, acute surgical nurses, bariatric service nurse practitioner and anesthesiology department. This nurse-led team standardized and improved the documentation of the assessment for nausea in the electronic health record and established best practices for the assessment and evaluation of preoperative nausea in those at risk and intra and postoperative nausea treatment.
Loma Linda University Behavioral Medicine Center members Sheena Martin, Raymond Norris, Tony Dharmaraj, Marlen Guerrera Clinical behavioral medicine nursing staff and leaders. This team is identifying best practices in the assessment and interventions for children admitted with Intermittent Explosive Disorder.
Publications Ekong, J, ‘Educating Home Healthcare Nurses About Heart Failure Self-Care‘, 34 ( 9 ): Home HealthCare Now2015 ; 500 - 506 D’Errico, E, Radovich, P, STAR2 Research Collaborative Partners Operational Failures in Frontline Nursing, (manuscript in review/revision) McMillan, K, Johnston, T, Hospitalized Patients’ Responses to Offers of Prayer, (manuscript in review/revision) McMillan, K, Radovich, P, The Effect of Massage Therapy on Pain and Anxiety in Medical and Surgical Patients, (manuscript submitted)
Presentations Michele Wilson, MS, CNS (LLUCH) did a podium presentation at the American Association of Critical Care Nurses National Teaching Institute conference in New Orleans, LA. Andrea Mason, MS, CNS (LLUSH EBP team) presented a poster at the American Society of PeriAnesthesia Nurses in Philadelphia, PA. In addition, Andrea and the team presented a poster and a podium presentation at the PeriAnesthesia Nurses Association of California conference in San Diego, CA. Brittany Jonas, RN (9200 and 9300 EBP team) presented a poster on the nurse driven CAUTI protocol at the Oncology Nursing Society national nursing conference in San Antonio, Texas. Susan Johnsen, MSN, COS-C (Home Care EBP team) presented a poster at the national conference of the American Academy of Ambulatory Care Nurses in Rancho Mirage, CA.
Kathy McMillan, MS and Beth Johnston-Taylor, PhD presented a poster on hospitalized patients’ responses to offers of prayer at the Western Institute of Nursing Research Conference in Anaheim, CA. Kathy McMillan, MS and Patti Radovich, PhD presented a poster on the effect of massage therapy on pain and anxiety in medical and surgical patients at the Western Institute of Nursing Research Conference in Anaheim, CA.
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Denise Petersen, NP presented a poster on using the CORE readmission risk calculator and socioeconomic data to determine 30-day readmission risk in Heart Failure patients at the Western Institute of Nursing Research Conference in Anaheim, CA.
An Evidence-Based Doctor of Nursing Practice Project Jennifer Newcombe, DNP, MSN, CNS, CPNP-PC/AC Nurse Practitioner, Pediatric Cardiothoracic Surgery
A Post-Operative Feeding Protocol to Improve Outcomes for Neonates with Critical Congenital Heart Disease Malnutrition is common among patients in the clinical setting and can affect clinical outcomes as well as cost. Evidence suggests hospitalized patients receive only 50-60% of their nutritional needs. Neonates with critical congenital heart disease (CCHD) are especially vulnerable for malnutrition during the post-operative period. Malnutrition in this vulnerable population can lead to delayed wound healing, bacterial infections, poor weight gain, extended hospital length of stay (LOS) and increased morbidity and mortality.
feedings 12 hours post extubation and advancing feedings and liquid protein at set intervals. The second algorithm was developed to objectively define feeding intolerance and nippling tolerance for CTICU nurses. The algorithms were built into the electronic health record (EHR) as order-sets. The protocol was implemented in the CTICU from August 2015 to March 2016. Twelve hours following extubation, nurses screened patients based on predetermined inclusion/exclusion criteria. If patients met inclusion criteria, the feeding protocol was started by the nursing staff.
In 2014, a retrospective chart review showed neonates in the Cardiothoracic Intensive Care Unit (CTICU) were not gaining weight during their hospitalization and met criteria for mild malnutrition at discharge. These neonates also demonstrated poor growth in length and head circumference from birth to discharge.
Twenty three patients were screened. Twenty-one patients met protocol inclusion criteria. Time to initiation of feeding protocol post extubation was 12.6 hours. Patients transitioned from intravenous fluids to goal feedings within 22 hours without developing feeding intolerance. Serum albumin levels and neonatal anthropometric measurements (weight, height and head circumference) increased significantly from birth to discharge. LOS for protocol patients was also lower than the national average, as reported by the Society of Thoracic Surgery (STS) database. The STS is a national database containing data from over 110 congenital heart programs across the U.S. and Canada.
A taskforce, led by a nurse practitioner, and consisting of critical care nurses, physicians, registered dieticians, occupational and speech therapists from the CTICU and Neonatal Intensive Care Unit (NICU) developed a post-operative enteral feeding protocol to improve nutrition outcomes. The protocol consisted of two evidence-based algorithms and criteria for donor breast milk. The first algorithm was designed to optimize calorie and protein delivery by initiating
A feeding protocol can provide the recommended caloric and protein requirements in a standardized and timely manner, thus reducing negative metabolic consequences that occur during the post-operative period. Other hospitals caring for neonates with CCHD may benefit from implementing a post-operative feeding protocol. However, success of implementation will depend on physician and nurse champions to facilitate implementation.
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Leading Us Into the Future
Jill Howie Executive Director Perinatal Institute
Gwen Wysocki Executive Director Staff Development
Karla Aryan Executive Director LLUMCEC, LLUSH and Urgent Care
Jeanne Messiniger Executive Director Center for Innovation
Sherry Nolfe Executive Director Patient Care Services LLUCH
Susan Markovich Executive Director Critical Care Services
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“I am honored to work with each member of our staff as we live our mission.”
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