Loma Linda University Health 50th Anniversary Nursing Annual Report by Brittany Fox

REPO

ANNU

20 17 The past 50 years have been a time of growth and change for the nursing profession, not only here, but internationally ... Over the next 50 years, events and treatments will take place here that we may not even dream about today.

The past 50 years have been a time of growth and change for the nursing profession, not only here, but internationally ... Over the next 50 years, events and treatments will take place here that we may not even dream about today.

TABLE OF CONTENTS Letters from the Chief Nursing Officers....................................................................2 Nursing Statistics......................................................................................................6 50 Years of Nursing....................................................................................................8 Quality Core Measures............................................................................................10 Infrastructure Areas that Cross Entities...................................................................12 Professional Governance ........................................................................................16 Nursing Leadership..................................................................................................19 Perioperative Services.............................................................................................20 Operating Room......................................................................................................23 Emergency Department..........................................................................................28 Adult Services ........................................................................................................30

ABCDEF Bundle......................................................................................................35 Cardiology, Cardiothoracic Surgery Units................................................................36 Loma Linda University Medical Center East Campus ............................................38 Loma Linda University Surgical Hospital.................................................................39 Loma Linda University Childrenâ&#x20AC;&#x2122;s Hospital..............................................................42 Nursing Certification Journey..................................................................................47 Loma Linda University Behavioral Medicine Center................................................50 Loma Linda University Medical Center â&#x20AC;&#x201C; Murrieta..................................................54 Clinics......................................................................................................................58 Institutes..................................................................................................................60 International Mission Trips.......................................................................................63

Loma Linda University Medical Center The Only Thing That is Constant is Change 2017 marks the 50th anniversary of the “clover leaf” towers. It was July 1967 that patients were moved from the “old hospital up on the hill” to the new towers. I joined the nursing team here in the summer of 1971. Recently I was rounding on the units when I took a minute to look around at the environment. As I looked around I began to notice all the things that were not on the units when I began. In 1971, nurses were wearing white dress uniforms, with white stockings and, yes, our nursing caps. Out with the “whites” and in with the navy blue scrubs, a much more practical option for care givers. There were no computers, no AcuDose, no cardiac monitors, no IV pumps, no IV bags. Yes we administered IVs, but the solution came in a glass bottle and we counted the drips to calculate the rates. We marked the amount the patient received by putting a line on a piece of tape we placed on the bottle. We took vitals using a blood pressure cuff, a stethoscope and temperatures using glass thermometers. But very soon things began changing.

“We have opportunities to become more involved with our local community as we assist our patients through the transitions of care. This is an exciting time to be a nurse at LLUH.”

When the towers opened, floors eight and nine were not completed, but over the next three years they were finished and occupied. Surgical services was on the eighth floor, with oncology and pulmonology on the ninth floor. In 1967 when the hospital opened, there were 10 licensed emergency department

2017 NURSING ANNUAL REPORT

(ED) beds. Today we have 54. In 1968 Loma Linda University Medical Center (LLUMC) did its first kidney transplant. The development of the intensive care units (ICU) began in the early 1970s, which currently total 100 ICU beds. The first adult heart transplant was performed in the mid-1970s. By the late 1970s to early 1980s, nurses from 7100, the cardiac ICU, were going overseas as members of the Loma Linda Heart Team. Our first nurse transport team started in about 1980. By the mid-1980s nurses began using computers for some tasks. In 1995, the first electronic medical record (EMR) by Hewlett Packard, CareVue, was rolled out on unit 8100. In 1991, the psychiatric patients were moved from unit 4300 to the Loma Linda University Behavioral Medicine Center (LLUBMC). In 1993, Loma Linda University Medical Center East Campus (LLUMCEC) nursing joined the adult services family. In 2003, Cerner was rolled out one unit at a time, taking nearly a year to implement. Many lessons were learned, so when LLEAP, our current electronic documentation system from EPIC, came along in 2013, we rolled it out with a â&#x20AC;&#x153;big bangâ&#x20AC;? methodology. In 2009 our adult nursing family expanded again with the addition of Loma Linda University Surgical Hospital (LLUSH). During 2017 we have been focused on the four areas of our strategic plan: quality, employee engagement, patient experience and meeting financial goals. We have made progress in

all of these areas. Our hospital acquired pressure injury (HAPI) events are below national benchmarks. We have implemented standardized procedures to reduce our catheter associated urinary tract infections and central line associated blood stream infections rates. Falls with injuries are below national benchmarks. Rehabilitation has gone six quarters without a fall with injury. Nurse hand washing is above 80 percent; our goal is to be at 95 percent or above. Our patient experience scores are improving each quarter. The annual employee engagement survey was completed in September and October of 2017. At the time this went to press we did not have the results, but with the implementation of leadership rounding I expect to see the numbers improve. About half of the nursing units met the goal of reducing incremental overtime by 50 percent by the end of December. 2017 marks the start of our Magnet journey. All of the adult inpatient units have a professional governance council and staff have become engaged in unit process improvement. 100% of our nurse leaders have a Bachelor of Science in Nursing (BSN) or higher nursing degree. And through a partnership with the Loma Linda University School of Nursing (LLUSN), 35 of our registered nurses (RNs) are enrolled in an associate degree (AS) to Bachelor of Science (BS) program and nine graduated in June with their BSN. So what will 2018 hold for nursing at Loma Linda University (LLU)? We will need

to be master change agents because I can promise you that there will be more change as we strive to surpass nursing benchmarks and be the preferred place to work. We will continue to improve our quality metrics. We will continue to implement our Connect-GRETE communication model. We will continue our Magnet journey by involving more staff nurses in decision-making committees. And as we watch the new hospital rise up out of the ground, we will begin planning for the next big move. The past 50 years have been a time of growth and change for the nursing profession, not only here, but internationally. We can offer high-tech care without losing focus of our core values of compassion, integrity, excellence, teamwork and wholeness. We have opportunities to become more involved with our local community as we assist our patients through the transitions of care. This is an exciting time to be a nurse at Loma Linda University Health (LLUH). Over the next 50 years, events and treatments will take place here that we may not even dream about today. As your chief nursing officer I feel fortunate to have experienced the past but to also be a part of the bright future for nursing at LLUH. Sincerely,

Jan Kroetz, MN, RN, NE-BC Chief Nursing Officer Loma Linda University Medical Center

Loma Linda University Children’s Hospital

“We cannot let a fear of failure, a fear of comparison or a fear of judgment stop us from doing the things that will make us great. We cannot succeed without the risk of failure. Individually, we cannot have a voice without the risk of criticism. Therefore we must risk, we must lead with our hearts and minds as we leave footprints in the sands of time.“

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Dear Colleagues, This is the time to give thanks, and my list begins with you. If you ever think that your job as a health care professional and supportive community goes unappreciated, I want to use this message to tell you that you inspire me every day. In the words of Charles Dickens, “The sun himself is weak when he first rises, and gathers strength and courage as the day gets on.” This has been a year of great change and we collectively have begun our Magnet journey and we get stronger every day. We are committed to the three goals as outlined by Magnet to continue to: • Promote quality in a setting that supports professional practice. • Identify excellence in the delivery of nursing services to patients and residents. • Disseminate best practices in nursing services. We are formalizing processes and communication pathways that are replicable, allowing successes in one unit to spread to others. Loma Linda University Children’s Hospital (LLUCH) needs to continue to maximize the impact that we have on our community, our patients and our staff. Nurses remain the most trusted professionals and this forms the bedrock of integrity and trust, it is a hallmark of our profession that we serve, first and foremost the patients and families whose lives we impact.

We cannot let a fear of failure, a fear of comparison or a fear of judgment stop us from doing the things that will make us great. We cannot succeed without the risk of failure. Individually, we cannot have a voice without the risk of criticism. Therefore we must risk, we must lead with our hearts and minds as we leave footprints in the sands of time. I am reminded that powerful dreams inspire powerful action, we need to dream on. I am inspired by the immediate successes of professional governance and the resulting changes that touch patient’s lives every day. Your bold and collaborative spirit is impacting the way patients feel, look, smile and tackle their own illness. Where are we going? When we can taste, smell and touch our dreams, we can enroll the world as we provide innovative, caring, cutting edge therapies to meet the needs of the sickest in our communities. Why are we going there? Because our mission is “to continue the teaching and healing ministry of Jesus Christ, ‘to make children whole,’ in a setting of advancing medical science and to provide a stimulating clinical and research environment for the education of physicians, nurses and other health professionals.” • Our new tower is progressing and will actualize Vision 2020. • 26 of you are actively participating in the RN-BS program and six have already

graduated from the program set up with Loma Linda University School of Nursing and many more are in other programs. Some of you are pursuing graduate-level work, all with a focus on excellence. I look forward to your continued commitment to our children and families. • We have initiated multidisciplinary pathways and are beginning to work on sepsis as part of the Children’s Hospital Association collaborative with at least 40 other children’s hospitals. We embark on this mission with a lofty but important goal of decreasing mortality and hospital acquired sepsis by 75 percent. I am excited to see the results we can achieve when we combine evidencebased practices and data with our dedicated and excellent staff at LLUCH. I am honored to work with each one of you as we live our mission. Hippocrates said, “Cure sometimes. Treat often. Comfort always.” Please contact me with your thoughts, ideas, creativity and innovation as we work together to advance nursing at LLUCH. 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, RN, NE-BC Chief Nursing Officer Loma Linda University Children’s Hospital

Nursing Statistics Intensive Care Units Loma Linda University Medical Center

Loma Linda University Children’s Hospital

Loma Linda University Medical Center East Campus

Loma Linda University Surgical Hospital Loma Linda University Medical Center – Murrieta

Nurses in acute care, ICU, clinics, perioperative areas and institutes

875 970 173 80

Loma Linda University Medical Center Loma Linda University Children’s Hospital Loma Linda University Medical Center East Campus Loma Linda University Surgical Hospital

418 368 17

Loma Linda University Medical Center – Murrieta

Ancillary areas

Infrastructure

2017 NURSING ANNUAL REPORT

Patients seen per year on inpatient units

93,830 Loma Linda University Medical Center

86,254 Loma Linda University Childrenâ&#x20AC;&#x2122;s Hospital

Patients seen in acute rehabilitation

ď&#x192;ą 18,372 Nurses with doctorates

2 PhD

15 DNP

30,687

Loma Linda University Medical Center East Campus

3,644

Loma Linda University Surgical Hospital

National certifications

RNs 7

obtaining certifications in specialty areas

50 Years of Nursing

CELEBRATING our cloverleaf hospital towersâ&#x20AC;&#x2122;

A NNIVERSARY th 50

1967-1977 Ken Peterson, RN I began my career as an licensed vocational nurse (LVN) on 9100 in November 1974. Nursing administration had a small footprint and there was no such thing as a computer. The most significant differences in nursing at LLUMC would be an all RN staff, nursing

administration has a larger footprint, computers and electronic documentation, an increase in regulatory requirements and responsibility for financial stewardship and unit management. 1978-1987 Patti Radovich, CNS During the late 1970s and into the early 1980s critical care was very different from today. The Swan Ganz catheter had recently been invented and when we wanted to place one of these catheters, we moved the patients into room 12 (8112) as this was the only room with the monitoring needed to care for these patients. When we obtained cardiac outputs we used cardiogreen dye which was sometimes visible on lab coats when pressures were too high and the dye exploded all over us. Additionally, when we provided aggressive pulmonary toilet we used Circle beds and Stryker frames to move patients from their backs onto their stomachs. It was a â&#x20AC;&#x153;wild rideâ&#x20AC;? for both patients and staff. Today we have moved from invasive monitoring to monitoring patients non-invasively while still providing high quality care. Janelle Warren, FNP-BC I began my nursing career at LLUMC in 1983 as an RN on a medicine unit. In those days we were part of the health care team, but knew our place and position in the hierarchy of caregivers. We answered to the physicians, and the patient

and family were included in the care, but not to the extent that they are today. As nurses, we are shifting from a maternal/paternal viewpoint of how we care for the patient to one of collaboration and mutual decision-making. This has enabled the nurses to collaborate with the physicians more readily as they advocate for the patient and family. Working in a multidisciplinary team with mutual respect among the providers leads to safer and more efficient patient care. The advent of nurse practitioners in the hospitals and clinics as a routine has been one of the biggest changes over the last 20 years. 1988-1997 Cheryl Stone, RN When I first started nursing at LLUMC in 1989, we were paper charting, mixing some of our own drugs from scratch and calculations for administration of drugs were all completed by our own math skill abilities. The physicians, nurses and ancillary teams all worked together as a close team, or family as I felt, to heal the patients and nurture the families through their time of crisis. There are so many major differences in nursing today than when I started back in 1989. It is a much safer environment for the patient, since we are using evidence-based practice and are questioning why we are doings things instead of feeling that is the way it has always been done.

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Sally Rajcevich, RN I laugh when I look back at the difference in technology from then to now. When I started working as the only pediatric gastroenterology (peds GI) nurse in 1990, we did not have EPIC or any other scheduling system. Our peds GI lab schedule consisted of a pocket-sized at a glance schedule which I carried faithfully in my lab coat everywhere I went. Also, before software programs existed, many hours were spent dictating results of reflux studies into a small cassette recorder. The tiny cassette tapes were then sent off to dictation services to be typed. What a change. 1998-2007 Audrey Maxton, RN I started working at LLUMC in November 1998. LLUMC unit 4800 made me feel welcome and treated me as part of the team from the very start. Teamwork is how I would describe nursing here at LLUMC. The biggest difference I have observed is how my peers and management encourage each other to obtain higher credentials in nursing. 2008-2017 Crystal Robinson, RN I began my career at LLUCH on 5800, the pediatric cardiac ICU/solid organ transplant unit. When I started, we worked 12 hour shifts,

starting at 0630/1830. We did many operating room (OR) procedures at the bedside such as chest closures, wash outs and extracorporeal membrane oxygenation (ECMO) cannulation. We charted everything on paper, even our drip calculations. Patients were monitored electronically, patient ratios were standard 1:1, 1:2, 1:3 and even at times 2:1. We have a very close relationship with our cardiothoracic surgeons, cardiologists and pediatric intensivists. We all work together, support each other and ensure that the team is focused on what is best for our patients. The biggest thing to change was the name of our unit to the Leonard L. Bailey Pediatric Cardiac Intensive Care. It was so wonderful to be there for this special moment. As we are a teaching facility there is significant turnover and a willingness to try new processes. So as of this last year, shifts start at 0700, rounds are done differently but are focused at providing prompt and efficient care to our patients and their families. We no longer do as many procedures at the bedside, charting is all done on the computer and most of the nurses never have had the privilege of experiencing paper charting or learning how to read a physicianâ&#x20AC;&#x2122;s orders.

Quality Core Measures Hospital Acquired Pressure Injury Hospital acquired pressure injuries are a national concern due to their impact on patient morbidity, quality of life and cost of treatment. In the last year, LLUMC has been able to achieve better-than-benchmark rates for five consecutive quarters. A dedicated wound care team with certified wound, ostomy and continence nurses (CWOCN) and physician champion have spearheaded a new process called “SHIELD rounds”. During shield rounds, the CWOCN team provides face-to-face education to staff about how to prevent HAPIs. Additionally, each unit has designated frontline nurses to serve as skin champions and experts. The wound care team and unit champions have helped ensure that patients receive the highest standard of care here at LLUMC. Skin Care Champion Program In March 2016, the wound, ostomy and continence nurses (WOCN) developed and piloted a Skin Care Champion program consisting of 12 staff RNs who were enthusiastic and passionate about skin care on units 7100, 7200 and 7300. The program, designed and implemented by the WOCN team, consisted of 216 training hours: four hour classroom sessions, three-to-four hour shadow shifts, a two hour debrief huddle and a meeting every six weeks with the WOCNs and skin

champions. In addition to the education and training, pressure injury prevention products such as the use of a waffle mattress for high-risk patients were also implemented. Six months after program implementation, reportable HAPIs decreased by 50 percent and for another six consecutive months, no reportable HAPIs were identified on all three units. In addition, the skin champions expressed increased professional satisfaction, increased ability to assess different types of wounds, including those related to pressure injuries, and significantly improved individual practice for pressure injury prevention. A large majority of unit staff also expressed their personal confidence and improved ability to assess and treat pressure injuries as well. Needless to say, the program was highly effective in decreasing HAPIs and increasing nursing satisfaction. Because of the pilot’s success, the Skin Care Champion program has expanded to units 6100, 6200, 6300, 8300 and the inpatient units at LLUMCEC. By year end, roll out will include the remaining ICUs and acute care units for LLUMC and LLUSH. The WOCN team members include: Yvonne Fankhanel, BSN, RN, CWOCN; Kimberly Hanson, BSN, RN, CWON; Gina Jansen, BSN, RN; Eileen Martois, BSN, RN, CWOCN; and Liesel Miller, BSN, RN, CWON.

Bar Code Medication Administration (BCMA) Bar code medication administration (BCMA) is a significant contributor in improving the safety of administering medications. At LLUMC, all inpatient areas exceed the Health Information Management Systems Society goal of 95 percent compliance. By making BCMA a standard way of administering medications, patients are kept safer. HCAHPS, Patient Experience, Employee and Leader Engagement In 2015-2016 our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores left much to be desired. The system knew it had to do something, and decided to take a more focused approach to our patient experience. As one of the strategies for a more focused approach, LLUH brought on Jennifer McDonald, executive director of patient experience, to lead us in these endeavors. Since her start here we have instituted new patient care boards,

2017 NURSING ANNUAL REPORT

specific to adult, children’s, mother/baby and rehabilitation. We created and implemented new patient discharge folders at LLUMC, Loma Linda University Medical Center – Murrieta (LLUMC – M), LLUBMC and LLUCH in English and Spanish. We created an entirely new communication model which was designed to be incorporated into the CLEAR Whole Person Care Model, marrying patient experience and mission together for the first time in our LLUH history. Our communication model, CLEARCONNECT-GRETE, was born in March 2017 and it has been integrated into every service training model. • LLUH facilitated our very first Service Best Practice Summit whereby leaders from all entities of the enterprise gathered in one room to begin a global service best practice transformation. The goal is for LLUH to become the best place to work, practice and receive the highest quality, safest care in the most compassionate environment. • One of summit’s fruits was setting a dedicated day and time for weekly leadership rounds on staff. Tuesdays from 2-3 p.m. was dedicated and began in July 2017. • On the horizon are new patient guide books for each entity, to provide our patients and families the necessary information to navigate their care.

2014

2015

2016

2017

Care Transitions

54.9

53.7

53.3

53.2

Cleanliness and Quietness

57.8

55.5

55.7

Communication About Medication

63.4

65.3

66.3

Communication with Doctors

79.5

80.3

81.4

81.9

Communication with Nurses

77.6

78.4

78.7

Discharge Information

88.5

88.9

90.4

Overall Rating of Hospital

73.9

74.3

73.1

74.7

Pain Management

69.5

71.6

71.7

Responsiveness of Hospital Staff

57.7

59.1

57.9

62.2

Would Recommend Hospital

81.3

80.8

81.7

80.9

The key to success from Jennifer’s perspective is that everyone who serves at LLUH does so with a mission driven, patient-centric approach and that all associates and medical staff are made to feel valued and appreciated for the great work they do. Our leaders are dedicated to a culture of Christ’s compassionate service and as long as we stay focused on that mission we will not fail.

The table demonstrates the remarkable improvement that Jennifer, along with our nursing leadership and nursing staff, have accomplished. While the battle to improve our scores is far from over, nursing continues on its journey to making the patient experience the best it has ever been.

Infrastructure Areas that Cross Entities Supplemental Staffing Network (SSN) Marie Hodgkins RN, MBA, NE-BC and Jet Role RN, MSN In 2015, LLU hospitals spent $13 million in registry utilization. As a result, an in-house registry proposal was presented at the operations committee on February 2016. Marie Hodgkins was asked to lead this project as the executive director and Jet Role, a nurse leadership resident, transitioned to become the SSN manager. From February to September of 2016 work focused on building the department. Other organizations with a similar program were consulted, data was analyzed with decision support to determine cost and projected savings, and different departments worked with the team to adapt clinical policies, job descriptions and other operational standards needed to operate SSN. In January 2017, SSN began supporting clinical areas, deploying eight patient care assistants (PCA) and eight RNs. SSN is steadily growing in number, working tirelessly to be a consistent staffing support to clinical areas. Through SSN, staff can work when they want and where they want. This attracted applicants who have full time jobs and wanted supplemental sources of income or are transitioning to full-time students.

• SSN has become the central hub for contingent workforce management. Prior to this, clinical and non-clinical contingent workforce was managed by central staffing and human resource management. The centralization of managing contingent workforce has helped in standardization of processes and streamlining the point of contact for outside agencies and their processes. • SSN aims to promote healthy working environments in the areas it supports. The impact of SSN to nursing and hospital operations are as follows: Support clinical areas by sending SSN staff first then registry staff if necessary. Reducing registry utilization and overtime usage. Retention of staff though flexible work schedules. Assess unit experience through e-forms. DAISY Award DAISY, which stands for Diseases Attacking the Immune System, is an internationally recognized program designed to recognize nurses who provided extraordinary care. The DAISY Award was established by The DAISY Foundation in

memory of J. Patrick Barnes who died at age 33 of an auto-immune disease. The Barnes family was awestruck by the clinical skills, caring and

“Nurses understand the importance of meaningful recognition and its impact in patient care and team building.” compassion of the nurses who cared for Patrick, so they created this international award to say thank you to nurses everywhere. DAISY nominations are open all year, two honoree celebrations occur annually. The DAISY Award and Recognition Committee chooses honorees from different entities. The honoree designation is based on the impact of extraordinary care reflected in the stories submitted. DAISY celebrations are arranged to surprise the honorees. During the celebration, the honoree receives a sculpture called “Healing Touch”, a delicate piece from Zimbabwe. The implementation of the DAISY awards program received an overwhelming response. Nurses understand the importance of meaningful recognition and its impact in patient care and team building.

2017 NURSING ANNUAL REPORT

Angelika Ashburn

Heather Blaine

Lucinda Esparza

Carla Fischetti

Maria Gordon

Sarah Gregory

Luchia Hansen

Margaretha Kasim

Dawn Kirk

Susan Krider

Kelly Lamb

Joshua Masih

Patricia Radovich

Mimi Robles

Lauren Spence

Thomas Sweeney

Amelia Tiefenthaler

Hala Vos

Not pictured: Brian Billedo Rozann Causey Carl Santos Janelle Warren

Tadele Worku

Joanna Yang

Daisy Award Honorees

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What is Nursing Informatics? Healthcare Information Management Systems Society (HIMSS) Definition Nursing informatics (NI) is the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice. NI supports nurses, consumers, patients, the interprofessional health care team and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes and information technology. Comprehensive Stroke Certification Nursing informatics role in the stroke build was necessary because of the complexity of the build and workflow. Nursing informatics had to bridge the technical side of EPIC and clinical side of the stroke request and regulatory requirements to create a workflow that would work in the electronic health record. Nursing informatics was able to take the request along with the regulatory requirements and create an efficient workflow for nursing and physicians. This included multiple iterations of the build with many meetings driven by the nursing

informaticist with end users. Once the concept was created in the EHR, nursing informatics was responsible for testing and evaluating the new stroke tool. Once testing was validated on the build side, nursing informatics had to work with the end users for validation testing. Once the build was moved to production environment (where the documentation changes were built), NI helped the end users navigate the new work flows and processes created. They were also instrumental in developing the metrics and reports used to evaluate the comprehensive stroke program. Innovations • Enhanced the clinical documentation improvement process by working with physicians to address documentation prior to patients being discharged. This led to improved coding and reimbursement. • Collaborated with the sepsis program to create alerts aimed at improving patient outcomes. • Created a modified early warning system (MEWS) to help identify patients that may require an immediate medical intervention. • Collaborated with case management to allow physicians to fill out Centers for Medicare and Medicaid Services (CMS) forms electronically. This decreased the time

it took case managers to get approval for patient needs after discharge. • Decreased ICU nursing documentation by nine minutes per nurse per shift. • Created new auditing tool to improve nursing documentation compliance and completion per shift. • Implemented CareConnect, a collaboration with an organization to create work flows that are evidence-based and improve the care of our communities through the EHR platform. Future Contributions of Nursing Informatics • Use new functionality to improve current workflow leading to improved patient care and outcomes. • Use predictive analytics to assist in predicting outcomes, drive patient care and treatments. • Develop new care paths to drive patient-care based best practices using diagnosis and comorbidities and other data points that are captured in the EHR.

Professional Governance Professional governance is an organizational structure that empowers frontline nurses to have a voice in their practice by allowing for shared decision-making with leadership. Within LLUH, we have over 40 professional governance councils where members meet for up to four hours a month to work on projects that improve patient outcomes and impact their practice environment. Each council is chaired and co-chaired by a frontline nurse. The following stories highlight just some of the great work that our councils have accomplished through their expertise and countless hours of commitment. The Advanced Practice Registered Nursing (APRN) Shared Governance Council Advanced practice registered nurse (APRN) is a collective term which encompasses nurse practitioners (NP), certified registered nurse anesthetists (CRNA), clinical nurse specialists (CNS) and certified nurse midwives (CNM). For APRNs, the professional governance council addresses issues associated with advanced practice, research, education and quality improvement in order to provide the highest quality patient care in an evidencebased and cost efficient manner. This model provides a framework that aligns APRNs with the organization’s overall goals and empowers all APRNs to play an important role within our hospital’s strategic plan.

Our APRN professional governance council is currently working on the development and implementation of an APRN mentorship program. APRN mentors provide knowledge, advice, challenges and counsel for an APRN newly hired into a new role or that have recently completed their education. The purpose of the APRN mentoring program is to encourage these individuals to take ownership of their own professional growth by focusing on concrete goals to accomplish during their orientation and track progress through annual evaluations. Mentoring has over time become an essential component in the development of transformational advanced practice nursing and is a key ingredient for growing and sustaining our APRNs. Pediatric Intensive Care Unit 5700 The pediatric intensive care unit (PICU) professional governance council is made up of 12 committed bedside nurses and a CNS. This council is committed to improving patient care and staff retention, through evidence-based practice. Some current projects are: • Developing a mentorship program with the goal of empowering new staff through support, guidance and growth. • Reducing cross contamination and costs by decreasing stocked supplies in nurse server, without compromising patient care.

2017 NURSING ANNUAL REPORT

• Standardizing linen on patient beds and cribs to decrease waste and promote accurate patient weights. The PICU professional governance council also works closely with leadership to be an advocate for patients and frontline staff. Acute Care Pediatrics Our professional governance council has made innovative improvements to our unit. Our quality and safety projects are HCAHPS driven, focused on decreasing pain during uncomfortable procedures. Additional activities include: • Production and trial of an isolation education pamphlet to increase compliance with isolation precautions amongst visitors. This project has improved compliance by 10 percent. • Production of an education flyer for parents and families during their transition from the emergency department to the inpatient setting. The hope is to ease the transition and improve patient satisfaction. • Working hand in hand with our charge nurses to improve communication between nurses. • In response to our Gallup survey, we have developed thank-you packets and surveys for nurses who come from other units to work with us when we are short staffed.

• We are piloting an education board to increase awareness of our various recognition awards and programs aimed at recognizing staff for the excellent patient care they provide. Cardiology Services The professional governance council includes nurses from all the cardiac units on the floor (7100, 7200 and 7300) who love to brainstorm great ideas together. If you give them a problem, they want to fix it. This group of talented nurses, from diverse backgrounds, all share a deep passion for making the care we deliver better for our patients and their families. We have worked hard this year, putting together “Stroke Buster” education when the hospital was working on its comprehensive stroke certification. One group developed handwashing badges for staff to wear, in our efforts to remind staff, patients and patients’ families to wash their hands. The council saw a need for staff to be acknowledged in their efforts to improve hand-washing. They created a box where we could place the names of staff that performed quality hand hygiene during the shift. All specialties are included in this drawing—nurses, doctors, respiratory therapists and other ancillary staff. Every six weeks during our meetings, we select a name from each unit’s box (7100, 7200 and 7300) and award the person chosen with a

gift card and public recognition. As a team, we continue to seek opportunities to give excellent care to our patients. Neurology Intermediate and ICU Unit 9100 The professional governance council on unit 9100 consists of nurses from both day and night shift as part of LLUMC’s Magnet journey. Our nurses serve on various committees within professional governance: patient satisfaction, employee engagement, quality of care and environment of care. As a team, our goal is to assess for areas of improvement as well as identify strengths within these categories

“Professional governance is an organizational structure that empowers frontline nurses.” to determine how we can foster continued growth of our nursing staff in order to best serve our patients and their families. We believe that creating a positive work environment and providing nurses with the tools and resources they need, will result in a higher level of patient care. Since forming our committee, we have begun to plan and implement different projects addressing goals that we have set collectively based on the needs of our patient population and staff.

These include: • A suggestion box for our unit nurses to share their ideas as part of employee engagement. • Working with nutritional services to ensure that patients admitted overnight can receive meals in order to increase patient satisfaction. • Implementing a daily unit clean-up to promote room and overall unit cleanliness. The quality of care committee is also working to collaborate with physicians in combatting and reducing the number of infections resulting from central lines and urinary catheters. It is our hope that each of these projects will lead to improved patient outcomes and a unit staff that feels supported, valued and skilled in providing excellent patient care.

2017 NURSING ANNUAL REPORT

Nursing Leadership

Leadership Residency In 2017 the leadership residency program provided an opportunity for a baccalaureate prepared nurse to develop leadership and research skills and to pursue a career as a future nurse leader and researcher at LLUH. The resident who has been given this opportunity is Delia Linch, BSN, PHN, RN, CRRN. Prior to accepting this residency Delia was employed at LLUMCEC for eight years in the acute rehabilitation unit. This residency includes rotations with leaders and mentors across LLUH organizations during the first year of the residency. The second year of the residency will be under the mentorship of the director of nursing research, Patti Radovich, PhD, CNS, FCCM. Delia will be given direct opportunities to work with leadership in the areas of evidence-based practice, research and grant writing.

Janelle Warren, FNP-BC Janelle received the President’s Award at the LLUSN conferring of degrees ceremony on Saturday, June 11, 2016. The university bestows the award to one exceptional student from each school. Janelle, who recently completed her doctor of nursing practice degree, works as a post-operative nurse practitioner in LLUMC’s urology department, where she collaborates with physicians, residents, interns

and nurses in evaluation, diagnosis and care management.

Maxine Darling, RN, MS Maxine was presented the Lifetime Service Award during the LLUSN commencement on Saturday, June 11, 2016.

LLUMC. She supervised the move of the operating rooms from the hill in 1967 to their current location. She has witnessed and supported much advancement in surgical procedures at LLUMC, including the Baby Fae heart transplantation.

Maxine received her diploma in nursing from then Portland Sanitarium and Hospital. She earned her master’s degree in 1960. Upon receiving her master’s degree, she was appointed supervisor of the LLUMC operating room. She has been a part of significant milestones at

Noted for diligence, attention to detail, clinical interventions and problem-solving skills, Janelle co-developed LLUMC’s palliative care consultation service designed to provide physical, emotional and spiritual relief to terminal patients. She also created software to simplify the difficult male Foley catheterization process and provided training to 200 nurses on how to use it.

Today, Maxine is an example to the new generation as she continues to work three days a week. She comes to work with enthusiasm and commitment to excellence. She is an example of living our values.

Perioperative Services IIsa Nation Executive Director

Thelma Chaffee Director

Karen Alvarez Director

Jeffery Robinson Director

Maria Letts Director

Marianne Schul Director

Luz Abadilla Manager

Valerie Adams Manager

Natalia Caines Manager

Lydia Calinison Manager

Deborah Damazo Manager

Eldine Mogenson Manager

Linda Puma Manager

Joe Wilkinson Manager

22,352

18,919

Dionnie Roxas Manager

21,361

Julie Quintana Manager

21,429

Alice Ong Manager

19,484

Jordan Mojica Manager

18,058

Sendy Chuop Manager

17,291

Stanley Manners Director

16,187

PACE visits by year

Not pictured:

2010

2011

2012

2013

2014

2015

2016

2017

2017 NURSING ANNUAL REPORT

PACE Moving Forward Maria Letts, DNP, FNP-BC, NE-BC If you find yourself scheduled for an elective procedure requiring anesthesia you will likely need pre-anesthesia screening. Similar to other large academic institutions within the US, LLUH has been on the leading edge of evidence-based practice, providing valuable pre-anesthesia screening for patients for over 20 years. In 2009 the pre-anesthesia consultation and education (PACE) department was established as a central location for pre-anesthesia evaluation of patients for all areas within LLUH care systems. These areas include all operating room services for LLUH to include: LLUMC, LLUCH, Loma Linda University Outpatient Surgery Center (LLUOSC), LLUMCEC, LLUSH and Loma Linda University Health Beaumont-Banning (LLUHB-B). Additionally, patients requiring non-operating room anesthesia (NORA), for interventional radiology, MRI, CT scan, cardiac and gastrointestinal procedures are evaluated by PACE. The PACE clinic is primarily a nurse practitioner based clinic under a collaborative practice agreement with the anesthesia department. The department serves perioperative services with a supervising anesthesiologist as the medical director and a nurse practitioner as the director. Currently, the LLUH system houses

40 ORs, cumulatively, with a volume 25,692 patients (excluding NORA) for 2016. Our busy OR volume trickles down to impact PACE with 90-130 patients per day. As our volume continues to increase, we continue to maintain patient safety, provide quality care with efficiency, and collaboratively create a satisfying experience for our patients. Through collaboration with other services we are able to provide onsite laboratory services and patient registration. Partnership with other services has been essential in implementing evidence-based measures to improve perioperative care within the institution. For example, in 2016 and 2017: • PACE website integrated a risk screening tool to facilitate ease of use and access for PACE providers. • NP implemented a pre-operative smoking cessation project with options for referral to the LLU Center for Health Promotion and California Smoker’s Helpline (in progress). • LLEAP integrated a real-time tracker during each PACE encounter to enhance communication among providers; create an awareness and attentiveness to patient wait time; and decrease non-productive time. This quality improvement initiative resulted in decreasing our average wait time from two hours or more to 90 minutes or less.

Collaboration is a key driver to the success of our department. The time and effort it takes to coordinate care is often not evident to providers downstream. The story below gives a brief glimpse of collaboration in action. “An extremely sick patient, presented at PACE with achalasia and 42 pounds of weight loss within six months. We had concerns of dehydration and malnutrition. In addition, because of the diagnosis of congestive heart failure, an echocardiogram was required. If not done prior to surgery, the case would be cancelled. The NP contacted both the attending anesthesiologist and the surgeon to collaborate and coordinate the patient’s treatment plan. All of this had to occur within the next 12 hours as surgery was scheduled the next day. Her persistence in getting the tests done ensured that this surgery would occur as scheduled, aiding ultimately in her recovery.” Alicia McPherson, PACE RN

Certified Registered Nurse Anesthetists (CRNA) Joe Wilkinson, BSN, CRNA Quality Improvement In order to improve outcomes, health care processes and organizational structure includes the expansion of certified registered nurse anesthetists representation and participation on hospital wide committees/councils. Currently, our contributions have been on the following committees/councils: • Anesthesiology quality improvement committee • Process improvement committee • Service best practices • Perioperative professional governance council • Advanced practice registered nurse professional governance council Essential to our practice is the handling of medication (ordering, mixing, administering, wasting and transportation) in the operating room and non-operating room anesthesia settings. • We are in the process of collaborating with our anesthesiology, pharmacy and patient safety coordinator colleagues in establishing

best practices and policies throughout the perioperative phases for all providers in the handling of medications in the above mentioned settings.

“We hope to continue to grow the mentorship program.” Our advanced practice registered nursing (APRN) magnet project, a mentorship program, will be launched this coming August for our four new graduate hires. • This program is an expansion of our existing mentorship program, which includes more collaboration with our APRN colleagues and standardization throughout the organization. • We hope to continue to grow the mentorship program to all hires - both new graduate and experienced providers - in the months to follow. Up and running, with the support of our perioperative services colleagues, is “Interpreter on Wheels”, a mobile telecommunication service to assist patient, patient families and providers in communicating during the perioperative phase.

Additionally, the outpatient services facility has enhanced its pediatric anxiety reduction measures with the addition of an iPad. This has led to a reduction in the amount of prescribed sedation for procedures in pediatric patients. Community Engagement Community contributions are a collaboration of the nurse anesthesia department within LLUMC and LLUSN. The Loma Linda University Nurse Anesthesia Department is one of the only programs in the Inland Empire and surrounding areas to offer a “shadowing” experience to registered nurses who show interest in becoming a CRNA. Teams of academic, clinical staff and nurse anesthesia students participated on multiple mission trips to Honduras and the Pacific Islands. Loma Linda University Nurse Anesthesia and Anesthesiology Departments have hosted an international development opportunity for an anesthetist from Blantyre Adventist Hospital in Malawi. This facilitated his development of anesthesia techniques, and personal and professional growth.

2017 NURSING ANNUAL REPORT

Operating Room Quality and Service Improvement Operating rooms (OR) are expensive to run and hospitals need to strive to be efficient in them. The success of an operating room day depends largely on outcomes of the day’s first surgical cases. Maximal utilization of the OR requires on-time starts and efficient room turnover. An important first step to a more efficient operating day is to ensure the first case of the day starts on-time. When the operating day is delayed, the remaining schedule often follows suit, resulting in longer days, staff dissatisfaction and potentially, fewer surgeries. Adhering to a standardized process for first case starts can result in additional cases, decreases in overtime, and increased satisfaction amongst the staff, surgeons and patients. At the LLUMC OR, the first case starts initiative restarted on Monday, March 6, 2017. LLUMC’s first case is scheduled to start at 0715 (0900 on Wednesdays). We began collecting data and addressing issues that arose in order to prevent them from happening again. One of the strategies implemented included having the operating room manager visible on the floor between 6:45 a.m. and 7:15 a.m. They round on each operating room and the pre-diagnostic care unit (PDCU) in order to mitigate any potential

delays. Anesthesia and staff buy-in was immediate and the communication between all involved has resulted in the number of cases on time continuing to improve. Innovations The BITS OF BRAIN Binder is the brain child of the Medical Center OR neurosurgery team at LLUMC. As a quality improvement project the neurosurgery team chose “communication.” The team wanted a way of helping each other and also improving transmission of information more efficiently between team members, other OR staff, surgeons, perioperative techs and service line specialists. This would optimize patient care, improving clinical efficacy and operational efficiency.

The pertinent information needed was the what, where, when, how and why of new information - equipment, instruments, procedures and surgeons. Also, changes in surgeons’ preferences, equipment problems, substitutions and estimated time of return. Since its inception a year ago, the team have added, made changes and used the binder as an orientation tool for new orientees and other OR team members. The neurosurgeons have found it to be a useful tool and have asked to add notifications about their preferences and changes to the notes in the book. A general surgeon commented, when he had seen the Bits of Brain Binder, “Why don’t we have binders like this in the other specialties too?”

Hand Hygiene

Employee Engagement Patient Satisfaction

Led by new manager, Luz Abadilla, the LLUMC OR team has started the Targeted Solutions Tool (TST) Hand Hygiene Project. We are collecting baseline data. Participating in the TST will help the OR focus on hand hygiene as an aid to the infection prevention strategy.

Lorie Davis is a perioperative tech whose main duty is to transport patients from the preoperative holding area or the unit to the operating room. Every day she comes with a smile and gentleness. To Lorie, her job is to help the patients and their families feel comfort as they move into a scary place. Recently, a patient’s family recognized Lorie for the way she attended to the patient in the brief encounter. The patient was coming to the OR for a cardiac surgery. The patient and the family were scared but Lorie provided reassurance and a caring attitude. The family returned later to present a pin to Lorie as a token for their appreciation.

Traffic Control Tower The traffic control tower was created to help improve patient flow at the LLUMC OR. The LLUMC OR has a limited number of operating rooms with an increasing volume in all services. The traffic control tower helps move patients who are waiting for their procedure to either LLUMCEC OR or LLUSH OR. This helps reduce length of stay, improve patient satisfaction and more importantly, the patient receives care in a timely manner. Since October 2016, approximately 150 patients have been transferred by the traffic control tower. Storage Modification The north clean core has undergone a restructure. The shelving has been updated to improve efficiency and safety. The south clean core restructure is in progress and the south clean core restructure has been completed. The equipment storage has been moved to A-level.

Loma Linda University Medical Center East Campus Perioperative Services Karen Alvarez, RN, BSN, MBA, CNOR LLUMCEC perioperative services is a specialty department focused on meeting needs of the orthopedic, spine, plastic/reconstructive surgery and oral maxillofacial patients, whether they are acute care patients in our hospital, longer term patients in our rehabilitation center or coming in for outpatient surgery. Our beautiful campus radiates healing in the form of nature and service excellence. Such is true with our peri-anesthesia and surgical team; our close knit work family is passionate and dedicated to our patients’ surgical experience. This year

we have made a strong push to focus on the quality of our sterile processing department (SPD) with multiple quality improvement projects that derive from the desire to increase communication, safety and quality across all facets of the surgical cycle and team. Some of the quality improvement measures implemented have also been adopted by our sister SPD’s. Additionally, 80 percent of our SPD techs are certified. Our OR has also been involved with the department of neurosurgery in re-establishing and building up the Deep Brain Stimulator (DBS) program at LLUMC using the latest technologies. It is a fascinating and fulfilling surgery which gives the entire team a sense of accomplishment because it is one of the few surgeries in which we can see immediate patient outcome results and how the procedure will improve the patient’s quality of life. Loma Linda University Surgical Hospital, Outpatient Surgery Center and Perioperative Services Marianne Schul, RN, BSN, MBA, CNOR LLUSH specializes in robotic surgeries for urology, gynecology, general and bariatric service lines. Our quality focus has been on patient and physician satisfaction. Our familycentered feel makes this a hospital of choice for both patients and physicians.

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Students are invited to LLUSH two times a year to participate in a robotic simulation program with robotic surgeons lecturing the students on the benefits of robotic surgery. Then the students get actual hands-on robotic experience. LLUSH perioperative services also hosted the first active shooter drill, in collaboration with the department of anesthesia and local law enforcement agencies. Other projects are improving the time between cases, standardization and streamlining of operating room supplies and improving the discharge of surgical patients by obtaining post-operative prescriptions in a timely manner. Loma Linda University Outpatient Surgery Center (LLUOSC) LLUOSC specializes in pediatric and adult minor surgeries. Perioperative services provides an environment of short cases with minimal turnover time between those cases. There is a sense of close collaboration between the anesthesiologists, certified nurse anesthetists and the perioperative nursing staff. Decisions are made together and the patient experience is always the focus. LLUOSC nurses are doing the best every day to earn the trust from our patients, visitors, surgeons, anesthesiologists and other supportive health care personnel. We are putting what we have learned into practice in every encounter with our customers, using

(GRETE) to greet, recognize and introduce, explain the purpose, time and engage. The positive feedback we received so far from patients and families has been that the nursing staff are wonderful and loving and the patients love coming to LLUH; that the nurses went above and beyond to help them out; that the nurses took time to talk to them. We are working with administration to improve the physical environment of the facility. We hope to have a patient friendly pre- and postoperative areas for our patients and families when they are seeking treatment here with us. Several nurses are involved in shared governance this year. Through their voices and creativity we will enhance experiences for patients and the health care professionals and increase satisfaction. The shared governance projects include improving patient flow between the pre-operative area to the operating room to post-anesthesia and the ergonomic assessment of the department.

2017 NURSING ANNUAL REPORT

Loma Linda University Children’s Hospital Operating Room Jeffrey Robinson, RN, BSN, MSN

Loma Linda University Medical Center Peri-Anesthesia Debbie Damazo, RN, BSN, MSN

As a newer department, the LLUCH OR identified issues with skill sets, quality and engagement. As a result, the LLUCH OR leadership developed a multi-step strategic plan that included participation from all members of the team.

At LLUMC, four departments make up the peri-anesthesia units:

• The first step was implemented in the November, December and January in-services where the staff was educated on quality measures. Following this, the staff was given the full strategic plan including mission, goals, structure and roles. • The next session included a departmentwide activity in which the staff drove the goals and process improvement measures. Those goals were presented by the assigned individuals and other initiatives were given to the shared governance committee which has recently started. • This plan has resulted in a rate of zero surgical site infections for the first quarter of 2017, stable staffing, engaged personnel and an overall accountable team.

• The first is the post-anesthesia care unit. A few areas this unit addresses: it holds recovered patients for inpatient placement, provides care for outpatient evaluation clinic cardiovascular laboratory (OPEC CVL) patients overnight, completes TotalCare Birthing Center recovery service, when needed, manages family visitation when holding patients and discharges patients after-hours when unit 4300 is closed. • Next is unit 4300 which consists of two rooms (four beds) with the layover unit during the day and four rooms (eight beds) during the night to support ED patient placement. This area accepts inpatient to inpatient transfer patients for the CVL department to aid in CVL flow and efficiency, holds CVL and interventional radiology (IR) patients at times for inpatient placement and discharges patients home safely. Additionally, it is available for holding pre-operative patients

for late starting cases, and when open at night, provides accommodations for a family member. • Another area is the pre-operative area where patients are prepared for surgery, CVL and NORA cases. This area de-escalates frightened and/or angry patients and families waiting for surgery or procedures and provides prayer with patients. • The final area is the prediagnostic care unit (PDCU). This is where the staff ensure surgical and procedural consents are complete, agree with the OR schedule. The unit also encourages the surgeons and anesthesia staff to complete documentation. Additionally, the staff aids anesthesia with IV starts, epidural placement and blocks and assists with epidural blood patches for OB patients. Our peri-anesthesia staff love what they do and we believe have some of the highest longevity among departments. Having all of these wonderful staff members allows us all to sleep well at night, knowing that our patients are in good hands.

Emergency Department

Making Strides in Our Hospital and in Our Community

Connie Cunningham Executive Director

Shannon Canright Director

Charnell Casady Supervisor

Kim Coy Supervisor

Kelly Davis Supervisor

Randy French Supervisor

Kenny Lard Supervisor

Senaida Luna Supervisor

Leah Magnaye Supervisor

James Parnell Supervisor

Rosemary Peng Supervisor

The first major stride for the ED this year is project Stoplight. This project was a collaboration between the emergency department, trauma services and our community emergency medical service (EMS) providers. We realized that we had numerous communication barriers in the ED when it came to getting reports from EMS. We did pre-implementation surveys to see what staff and EMS thought were the biggest barriers and then we implemented the Stoplight program. Project Stoplight is a communication tool that implements closed loop communication and mutual respect. Before project Stoplight, when EMS would bring in a patient to the emergency department, the room would be loud and everyone would have hands on the patient which made it difficult to hear a good report. It created communication breakdowns which had the ability to impact patient safety. The process works like this: 20 Seconds for everyone to get in the room that needs to hear report (this is especially important in a teaching hospital). 60 Seconds for the paramedics to give an uninterrupted report to the ED team. 30 Seconds for the ED team to ask any questions. Then the patient is moved onto the gurney and treatment is rendered. It seems like such a small thing to do but the impact was huge.

2017 NURSING ANNUAL REPORT

The education for this process included ED staff training, EMS training at the local fire departments, with AMR on a county level with all of the EMS officers, as well as those in the paramedic training schools. This process has been presented at Loma Linda Universityâ&#x20AC;&#x2122;s annual research conference, California Fire EMS Disaster West, the California Nurse Leaders Association conference, the California State Emergency Nurses State Council meetings and many other venues. Hospitals nationwide have inquired about this process and are implementing it in their own hospitals and EDs. Community Outreach One community outreach project included a resume building and interview technique workshop for new graduate nurses. The emergency department paired up with the Inland Empire Emergency Nurses Association to host a class in which we went over interview techniques, critiqued resumes and did practice interview scenarios. We went to all the local nursing schools and put up flyers for an interview experience and had a great turn out. We invited the participants to bring their current resume and after the lecture portion of the class we did one-on-one counseling with participants regarding their resumes and answered any questions they had. This is the second year in a row that we have done this and we hope to continue.

This year was also our second annual community outreach in which we collect blankets and pass them out with meals to the homeless in San Bernardino county. Over the course of a year we collect the unsoiled blankets that come in with patients who arrive to the ED via ambulance, which would normally be thrown away. Once we have collected enough, our team picks a day and we head over to the laundromat to wash all the blankets.

We also buy meals, put together care packages of donated supplies such as scarfs, hats, socks, dog toys and dog food. After everything is washed and packed up, we load up and head into the community and start passing these out to the homeless in the San Bernardino area. At the end of the day it is safe to say that we all feel like we are the ones who received a blessing. It is an honor to serve our community in such a way.

Adult Services Loma Linda University Medical Center Intensive Care Unit Susan Markovich Executive Director

Penny Amornvut Director

Derrek Hidalgo Director

Stephanie Ferrero Manager

Donna Kotlar Manager

Jessica Fields Manager

Desara Shipley Manager

Corina Gallardo Manager

Therese Yasay Manager

Elma Gucilatar Manager

Not pictured:

Jacqueline Pangkey Manager

Renel Zezima Manager

Dan Hubbell Manager

Jan Wills Manager

2017 NURSING ANNUAL REPORT

Loma Linda University Medical Center Acute Care Unit Norie Bencito Executive Director

Louise Piotrowski Director

Jennifer Blackey Director

Donna Gross Manager

Kerry Burns Manager

Lindy Legoh Manager

Janet Jones Manager

Tiffany Lopez Manager

Josette Raguero Manager

Patricia Palacios Manager

Matthew Vos Manager

Loma Linda University Medical Center East Campus and Loma Linda University Surgical Hospital Karla Aryan Executive Director

LLUMCEC

LLUSH

Sherry Lee Director

Cydney Love Director

Gloria Molina Manager

Erica Levy Manager

Aimee Ochotorena Manager

Grace Shih Manager

Bertha Ruan Manager

Lisa Turner Manager

Emanuela Salajean Manager

Anette Nunn Director

2017 NURSING ANNUAL REPORT

Loma Linda University Surgical Hospital Wins Three Excellence Awards from NRC Health

Helen Hrdy (left), senior vice president of client service at National Research Corporation (NRC) Health, celebrates with Anette Nunn, director of patient care at LLUSH and Jonathan Jean-Marie, vice president and administrator of LLUSH.

LLUSH received three awards during a ceremony at the 23rd Annual NRC Health Symposium for PatientCentered Care on, Sunday, August 6, in Boston. The awards are given to health care organizations for dedication to improving the patient experience. Surgical Hospital received Patient-Centered Care Dimension Awards in three categories: continuity and transition, physical comfort and respect for patient preferences. NRC Health recognizes hospitals and health systems that have exhibited an exceptional

commitment to understanding individuals’ complete care journey. It calls award winners “elite organizations that have received the highest ratings of overall satisfaction by patients and their families.” Jonathan Jean-Marie, said only 30 hospitals from the United States and Canada received awards at the symposium.

Unit 9100 has been a leader in the hospitalâ&#x20AC;&#x2122;s efforts to reduce hospital acquired infections by keeping its CAUTI rates very low. Unit 8100

Caring and Teamwork in Critical Care Unit 9100 The neurology science critical care and stepdown unit underwent transformation from an extension of the medical ICU to that of a neurologic specialty unit. 2017 has shown huge growth in nursing care provided to those with neurologic disorders and in becoming a comprehensive stroke center through the Joint Commission. Our nurses have become specialized as stroke nurses providing focused care for patients who have suffered a stroke.

Surgical ICU has been a leader in the care of surgical and trauma patients. The surgical ICU continues to work with the LLUMC emergency department to provide care for patients from a variety of disasters, with teamwork and inter-professional collaboration. Additionally, the surgical ICU has been more involved in developing patient care improvement projects such as the upcoming implementation of continuous renal replacement therapy (CRRT) and training skin champions. In the area of infection control and minimizing hospital acquired conditions, unit 8100 has held its central line associated blood stream infection (CLABSI) rate at zero. Unit 4700 The medical ICU continues to take care of some of the most challenging patients in the community. To date, 30 RNs on staff have achieved their certified critical care registered nurse (CCRN) certifications, 59 RNs hold BSN degrees and four RNs have received their masterâ&#x20AC;&#x2122;s degrees in nursing. Examples of the staffâ&#x20AC;&#x2122;s dedication to improving quality and

reducing waste include the identification of effective pericare wipes at a reduced cost and efforts to reduce CAUTI rates. Intensive care collaboration is occurring within the department as well. The three units are working on a process improvement project to bring down incremental overtime. The service line managers and director are focused on staying financially aware and continue to seek opportunities to keep incremental overtime down. The department partnered with the Global Health Institute to develop opportunities for hospital nurses to participate in international trips with Adventist Health International and other international facilities. The collaboration will provide aid for many initiatives with clinical personnel providing education and care outside of LLUH, which includes the Joint Commission International Education Program. Our frontline staff partner with our international community in health education and nursing education. This initiative will allow for unit collaboration, teamwork and building community both locally and internationally.

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ABCDEF Bundle As a tertiary and quaternary care facility, LLUMC excels at providing quality care for high acuity patients. A constant focus for our team is how to ensure that our patients, requiring intensive care, are able to safely recover to the highest quality of life possible. This focus has led to the implementation of the ABCDEF bundle in our ICUs. The ABCDEF bundle is evidence-based coordination of care supported by national organizations such as the American Association of Critical Care Nurses (AACN) and the Society of Critical Care Medicine (SCCM). This coordination of care aims to free patients from mechanical ventilation earlier through the collaboration of an interdisciplinary team. This bundle starts with managing pain and sedation by utilizing evidence-based guidelines that provide a choice of medications providing a more wakeful state, which subsequently encourages early mobilization and simultaneous patient-centered focus involving the family. When implemented collectively, the ABCDEF bundle components of assessment, breathing, coordination and choice, delirium, early mobility, and family engagement and empowerment, improve quality outcomes by decreasing days on IV sedation, reducing risk for delirium and long term cognitive impairment, enable the awake patient to participate in mobility earlier to reduce the risk for muscle wasting and impaired mobility. The bundle has shown to decrease ventilator days and decrease length of ICU stay by up to three days. Many organizations

incorporate individual components of the bundle separately, while few incorporate the bundle as a coordination of care, which is essential to meet these metrics. We have a dedicated team motivated to change and sustain behavior that will benefit our patients in the ICU. The LLUMC interdisciplinary team responsible for progressing care of the ICU patient through the ABCDEF bundle consists of leaders and frontline staff representing nursing, respiratory, physical therapy, occupational therapy and pharmacy in collaboration with ICU providers across multiple hospitals. The ABCDEF bundle is another way that we, at LLUMC, strive to do what is best for our patients.

Assessment

Breathing

Coordination and Choice

Delirium

Early Mobility

Family Engagement and Empowerment

Cardiology, Cardiothoracic Surgery Units The seventh floor developed five professional governance teams that focus on quality improvement, core measures, staff empowerment and chart audit, patient satisfaction, equipment and environmental. The quality improvement professional governance (PG) team’s current initiative is focused on blood stream infection (BSI) prevention. We are trialing the use of Biopatch®, a protective disk impregnated with chlorhexedine gluconate that is effective against super-bug growth on peripheral intravenous sites.

“This will help with patient and family engagement on their plan of care.“

Teamwork and Collaboration for Successful Transitions

The staff empowerment professional governance identified that mended heart, a volunteer service which provides support to post cardiac surgery patients, did not have adequate resources to continue making the heart pillows. The post-operative coronary artery bypass graph (CABG) patients use the heart pillow as a splint when they are taking a deep breath or coughing. The heart pillow is an integral part of recovery as it makes it easier for the patient to take a deep breath or cough, which helps to prevent pneumonia. The team felt they should contribute to mended heart by making the heart pillows for the postoperative CABG patients. The team raised donations on unit 7100, 7200 and 7300 for the materials. Then the team volunteered their time to sew and stuff the pillows together. The seventh floor patient satisfaction professional governance implements the wellness binder for patients. The wellness binder is given to each patient who is being discharged with congestive heart failure (CHF) and postoperative CABG. The wellness binder is an organized way of providing discharge teaching material, patient instructions and follow-up visit information. A section in the wellness binder is focused on daily log sheet for the patient to put in their blood pressure, heart rate and daily weight. The bedside nurse is initiating the education on this section as soon as the patient and

family show a readiness to learn. This will help with patient and family engagement on their plan of care. The wellness binder also provides information on who to call when the patient has questions. The goal of this wellness binder is to increase patient satisfaction and decrease readmission rates. Acute Care Surgery Units Unit 4100 The Loma Linda University Medical Center Transplantation Institute celebrated 50 years since LLUH’s first kidney transplant and surpassed 2017 goals for all solid organ transplants. As we continue to streamline patient flow, unit 4100 is now taking kidney and pancreas transplants directly from recovery. To facilitate this change, we have implemented an ICU champion role to facilitate training new nurses in the care of our newly transplanted patients and developed a transplant competency. Unit 8200 Neurosurgery and trauma intermediate care nurses obtained the National Institutes of Health Stroke Scale (NIHSS) certification as well as other stroke training. As part of a collaborative effort, 8200 became a designated stroke unit during LLUH’s journey to certification as a Joint Commission Comprehensive Stroke Center. Over half of our nurses have completed the Trauma Care After Resuscitation (TCAR) course,

2017 NURSING ANNUAL REPORT

“8200 became a designated stroke unit during LLUH’s journey to certification as a Joint Commission Comprehensive Stroke Center.“ committed to increasing knowledge and clinical expertise in the setting of a Level I trauma center. Unit 9200 LLUMC’s surgical oncology unit, in collaboration with unit 9300’s evidence-based practice group, expanded its work on a CAUTI prevention project including the “Ticket to Ride” which is now going house wide. The Ticket to Ride program provided enhanced communication and urinary catheter care as the patient moves through the hospital during diagnostic testing. The evidence-based practice (EBP) group submitted an article to the Clinical Journal of Oncology Nursing which was published in the August 2017 issue. Additionally, unit 9200 PG is working on a process improvement project, named Kanban, for its supply room, which will reduce waste and increase efficiency. Unit 9300 The medical oncology unit is opening the adult bone marrow transplant program; nurses have completed the Oncology Nursing Society’s Bone and Marrow Transplant course and attended in-services in

preparation. In the area of infection control, the 4100 and 9300 PG is working on a multidisciplinary project, Five by Five, with the goal of this project being implemented house wide to decrease hospital acquired conditions including c-difficile. The c-difficile reduction team reviewed and updated the isolation signs, developed a visitor card that assists our families and visitors in better understanding isolation precautions and the actions needed. This card will be printed in English and Spanish. Acute and Intermediate Medicine Service Line Units 6100, 6200, 6300 and 8300 Units 6100, 6200, 6300 and 8300 are the adult medical-surgical units of LLUMC. The units have piloted and perfected Structured Interprofessional Bedside Rounds (SIBR), which has decreased length of stay by half a day. Our evidence-based practice (EBP) team implemented a pressure ulcer prevention project. The EBP team shared its project in poster presentations at three regional nursing conferences last year and this year it submitted an article for publication. The PG team wanted to focus on compliance with

nursing documentation and developed a two RN double-check. The next project is to encourage nurses obtaining their certification. In another endeavor to improve patient care, the units also started a wound/skin champions program. This allows its members to receive specialized training with the WOCN team, attend monthly classes, learn through online modules, and upon completion of all training, earn a certificate. The wound/skin champions now participate in SHIELDS rounds every month on the units to educate staff on preventative measures to decrease pressure ulcers. Further promoting nursing engagement, our units send three to six nurses to trauma care after resuscitation courses. This additional education improves patient outcomes by increasing the medical-surgical nurse’s knowledge and clinical skills in our Level I trauma center.

Loma Linda University Medical Center East Campus out. One particular patient has been an inpatient in the ICU for greater than 160 days. This patient is ventilator dependent and has been unable to progress to the point of discharge. The ICU staff takes this patient outside to the Healing Garden and to the rehabilitation gyms. The patient looks forward to these outings and enjoys the fresh air and sunshine facilitating early mobility and keeping oriented. At LLUMCEC, our goal is to support the Loma Linda University Health mission and vision to the best of our ability. We provide individualized and compassionate care to those entrusted to us. The following are just a few ways we excel in this endeavor: • Zero central line associated blood stream infections for 2017, with some units being free of CLABSI for greater than two years. Additionally, we have had zero reportable hospital acquired pressure injuries in 2017. • In order to prevent and minimize the spread of infection, a hand hygiene project was initiated in conjunction with the Joint Commission. Nursing compliance with hand hygiene has increased to 98 percent in 2017 as a result of this project. • Acute rehabilitation has been free of falls with injury for 2017. At LLUMCEC, we value each patient experience, but some stand

LLUMCEC has begun the Magnet journey. All units have implemented professional practice councils and are working to improve processes and delivery of patient care. Several LLUMCEC nurses are part of the Magnet planning groups. Evidence-based practice groups are actively engaged in projects. Acute rehabilitation has EBP groups working on patient falls and answering call lights. All these activities serve to improve the care delivered to our patients.

LLUMCEC has been involved in numerous innovative solutions to improve patient care. The following are just a few: • LLUMCEC leadership has implemented a phone application during rounding that allows alerts to be sent immediately to specific managers, making them aware of issues identified. This has helped with timely service recovery and resolution of patient concerns. • A multidisciplinary group, consisting of medical staff, nursing and quality, is working on the development of a sickle cell pathway. The goal is safe, effective and timely care of this patient population. The pathway will cover all transitions of care, from ED to urgent care to discharge.

2017 NURSING ANNUAL REPORT

Loma Linda University Surgical Hospital Professional Growth

Strides for Improvement Hand hygiene before and after patient care and/ or contact in order to minimize and prevent the spread of infections is something that has been at the heart of nursing at LLUSH. LLUSH’s compliance reports in the past year were dismal and did not exceed greater than 60 percent, which was quite discouraging. In order to improve our results and achieve our departmental goal for hand hygiene compliance, the leadership team met and brainstormed on ways to improve the LLUSH score. We strapped on the challenge of taking our low scores in the 60 percentile, and implemented a new approach. Since the implementation, our hand washing compliance has reached 92 percent. We are beyond excited and are confident that this translates to quality patient care. We are also now within the target of compliance for our nursing strategic goal regarding hand hygiene.

This past year, we have encouraged our nurses to begin the Magnet journey. Over half of our nurses are new to the unit, institution and the profession. For those who have settled in, we have encouraged them to advance their education and up the clinical ladder. We are proud that one of our nurses completed her BSN last year, three of our nurses are currently working on advancing their degrees and one is working on her MSN and NP program. Five of our nurses are advancing or have advanced on the nursing clinical ladder to clinical nurse C. A Look into Patient Care LLUSH has been blessed to have many valued relationships with its patients, but one family stands out to all of us. This particular patient touched the hearts of most of the staff. The patient was diagnosed with a rare type of bladder cancer, was admitted to our unit several times, and on each admission the staff wanted to be the patient’s nurse. They had a special connection with this patient. There were times when staff would simply sit in the patient’s room and talk with this patient, and each of the nurses found something that was a common thread between the two of them.

One family member was a remarkable woman who allowed the staff the freedom to provide the necessary care, even though she was an RN. She appreciated the dedication of the staff and shared with them on several occasions what a good job they were doing. Throughout the past one and a half years, the staff watched as this patient continued the battle and despite the pain and setbacks, the patient’s smile and determination was something that all took notice of. The staff requested a special prayer service for this family which our chaplain coordinated, and over half of the staff attended. When the disease finally won and the patient lost the struggle, several of the staff attended the funeral on their day off because their connection with the family was so impactful. The staff commented on how appreciative they were of the experience and felt that this patient provided lessons for them which will no doubt shape how they provide care for others in the future.

Pediatric Services

Sherry Nolfe Executive Director

Kristen Diaz Director

Rebecca Dolman Director

Truphosa Otianga Director

Shana Fujimoto Manager

Alane Allbee Manager

Jocelyn Ipsen Manager

Janae Jones Manager

Jennifer Pedersen Manager

Taryn Martinez Manager

Jeane Spaid Manager

Shelly Taylor Manager Not pictured: Scarlett Czarnecki Manager

Amber Olsen Manager

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TotalCare Birth Center

Jill Howie Executive Director

Labor and Delivery

Neonatal Intensive Care Unit

Joyce Ekong Director

Tristine Bates Director

Susan Bone Manager

Kathie Elloway Manager

Cynthia Grijalva Manager

Aloha Malit Manager

Joanna King Manager

Alice Vang Manager

Loren Neiswender Manager

Susan Rojas Manager

Heidi Seto Manager

Betsy Tan Manager

Maternal Fetal Medicine

Mariana Prieto Manager

Veronica Tsui Manager

Loma Linda University Children’s Hospital

Pediatric Intensive Care Teddy Bear Story In the LLUCH pediatric ICU, our role can quickly change from stabilization and life-sustaining support to supporting grieving parents and families. There have been many recent viral videos of families of organ donors hearing their child’s heartbeat for the first time in a donor recipient. This triggered an idea that maybe we can give parents a way to preserve the sound of their child’s heartbeat to help them as they grieve. One of our managers purchased sound recorders that can make a 10 second recording of a dying child’s heartbeat which are placed in a stuffed animal, so when you squeeze the bear, you hear the child’s heartbeat. This is an irreplaceable gift, and as you can imagine this can be an expensive project to sustain. We are excited to carry on this project and have been blessed by the Big Hearts for Little Hearts Guild in their donation of bears and recorders,

A Look at Our Units

to be able to continue to provide these bears to our grieving families, in those cases that we are able to get a recording of the heartbeat in time. The families that received these recordings were so incredibly thankful to be able to still hear their child’s heartbeat. The loss of a child is tragic and often unexpected, no one plans to come to the hospital with their child and leave without them, so giving this little memory of their child to take home with them is a gift we are thankful to be able to provide. 5800 Step Down 5800 Step Down is a 19-bed pediatric unit that provides telemetry monitoring for ICU and intermediate level patients. A big win for us this year has been our home ventilator (home vent) program. This is the primary unit for the home vent program which consists of more than 140 children. Once a year, each home vent patient comes to our unit for an annual tuneup (patient physical evaluation and ventilation equipment service). We are working in conjunction with the home vent clinic to steamline our services during this tuneup admission to provide patient and family satisfaction during their hospital stay. Because of our new process, we have averaged the highest number of patients per month admitted for their tuneups with two day

average turn around. This has not only been a win for our patients and families but also a win for the nurses who have the privilege of caring for these patients. In addition to this win we have now been CLABSI free for 52 weeks, have had no CAUTI year to date, and have increased our medication scanning compliance to above 95 percent. Acute Care Pediatrics Acute care pediatrics (ACP) is known for compassion. Being able to provide the best nursing care to our patients is extremely important to us. We have been blessed to have staff who are champions for evidencebased practice and use their knowledge to advocate for and provide the highest quality care to our patients. Hala Vos is one of those innovative nurses. She, alongside our professional governance team, championed and implemented the J-Tip device for IV starts. Being a child in a hospital can be a scary thing, especially when you have to get poked and prodded. The J-Tip, is a small device used prior to pokes (IV placement, LP, sutures, etc.), that numbs the area where a needle will be used to start an IV to ultimately help children experience these procedures in a whole new light. We are pleased that this innovation has been adopted on our unit, bettering the quality and experience for the children we serve. We could not have continued success on our units if it were not for

2017 NURSING ANNUAL REPORT

the dedicated nurses who see an opportunity to improve patient care and seize the challenge to make it happen. Hematology Oncology Much of this year has been focused on improving CLABSI rates and protecting our patients from infection. We have seen a drop in numbers since the beginning of the year through re-education about our central line bundle of care and we are continuing to develop improved care strategies and tools to maintain our improvement. In 2016 we had a total of 13 CLABSIs. In 2017 we have a total of three CLABSIs (a 77 percent reduction).

Community engagement is another big part of our culture and another area we are dedicated to. This last Christmas we sponsored two families, working with them to create wish lists and then making those wishes come true in their Christmas gifts. We picked one patient with sickle cell disease and one patient with leukemia to sponsor. We had them each create wish lists and we were able to buy all the items they requested. One family only had one bed and we were able to get Ashley Furniture to donate a new bed for them. In the past we have had local businesses help us by donating kitchen stoves, refrigerators and bikes. Our commitment to our mission is what drives our nurses to practice the highest level of quality and compassionate care that extends outside of our four walls into the community. Cardiac ICU The nurses of 5800 cardiac thoracic intensive care unit (CTICU) have been making many waves throughout the unit. The nurses of this unit are continuously looking for opportunities to improve patient outcomes and work hard to serve this great population of kids in our community.

When encountering a problem, the nurses do not just say: â&#x20AC;&#x153;this is the way weâ&#x20AC;&#x2122;ve always done it.â&#x20AC;? They are innovative and look for ways to improve processes so that they can ensure patient safety and high quality. One example is the OR vasoactive drip initiative. When the pediatric cardiology patients came to the unit from the OR, they had medications that were previously started by anesthesia in the OR to maintain their vital signs. However, when these patients come up to the unit, the cardiac surgeons must initiate new orders. This created a workflow problem for CTICU nurses because there might be variability in the orders and the medications coming from the OR and it could not be entered into the electronic health record because the patient did not have a bar code for scanning. These issues lead to unnecessary orders and the need for frequent medication changes, which could affect patient safety. The unit took on this quality improvement project and put a taskforce together. The taskforce met monthly to develop a new workflow that would allow a drip to be ordered in the OR, the barcode scanned in the CTICU and medications documented in nursing flow sheets. The revised workflow was implemented in March of 2016. To date, 100 percent of vasoactive medications started in OR contain a bar code scan. 90 percent of the time, nurses are able to bar code scan the medication and document it appropriately in the electronic health record.

Our professional governance council also helped make important changes to the way we exchanged patient information. The current process of exchanging information between shift reports was inefficient. This inefficiency resulted in unnecessary incremental overtime and costs of $6,000-$8,000 per pay period for the unit. The professional governance council sought to streamline the process and found that built into the current electronic medical record is a flowsheet to do a thorough but concise nurse to nurse hand-off. Only 25 percent of nurses were using this LLEAP EHR overview page. By implementing this process the professional governance council was able to standardize the method of exchanging pertinent information, allowing for a more efficient patient handoff, which brought cost-savings to their units. Neonatal Intensive Care Unit (NICU) The neonatal intensive care unit (NICU) at LLUCH has the capacity for 84 critically ill infants and is equipped to provide the highest level of tertiary and quaternary support for premature infants

with the most complex surgical and neonatal disorders. The mission in the NICU is to ensure that the highest quality of individualized, neuroprotective, developmentally supportive, family centered care is available to all newborns in intensive and special care nurseries. We emphasize developmentally appropriate care of neonates and culturally sensitive care as our patients come from many different ethnic and religious backgrounds. Quality • In order to reduce the incidence of necrotizing endocolitis and match the benchmarks at the regional level of California for infants weighing 401-1,500 grams or being 22-31 weeks gestation, we utilize changes in practice including:

Discharge Process Improvement Baseline Data Reasons for Discharge Delays After 1700  Parent delay 17%

31%

43%

Discharges Between 2/6/17-3/4/17 1% 42%

 Before noon  Before 1700  After 1700

57%

Reasons for 2+ Hour Delay in Discharge

Initiated an update in feeding protocols. Decreased number of residual checks. Monitoring and collecting data for 6-12 months tracking infant growth, tolerance and morbidity.

orders and signing discharge summary

 Miscellaneous

Expanded breast milk to 2,000 gram infants.

Trialled use of human milk fortification.

discharge training

 MD delay in writing

Increased breast milk use and donor milk.

Increased support and encouragement of breastfeeding mothers.

 Parents doing

 Parent delay 25%

28%

 Awaiting discharge order to be written

32%

15%

 MD summary

awaiting authentication

 Miscellaneous

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In effort to improve recruitment and retention of nurses, we have increased advanced training and added four new NICU transport nurses and two ECMO nurses. Additionally, the NICU has achieved 100 percent nurse staffing (no registry staff utilized) and now has a 10 percent nursing turnover rate. • In addressing organizational discharge concerns, baseline data was collected to identify ways to improve discharge times and patient satisfaction. A review of the current discharges found more than two hour patient delays with all discharges occurring after 5 p.m. Our teams are currently looking for ways to address these issues. Parent and Family Centered Care Storytelling Compassionate Care Compassion is something you cannot teach but is an essential attribute of a NICU nurse. Nurses build lasting and trusting relationships with mothers of infants who spend time in the NICU. We commit to and practice a philosophy that, “no one dies alone,” and NICU nurses keep that sacred promise made to mothers of the infants in the NICU. As one example, a NICU nurse sat beside a mother, who was overwhelmed by grief, too ill herself to endure the watching and waiting for her infant to pass.

The NICU nurse stayed and kept her promise made to this mother and held her precious infant through episodes of kussmaul breathing and slowing heart rate cycles until this infant took his final breath and passed from his earthly home. This nurse gave this mother comfort, compassion and grace and honored her by showing her how we pray. A Triple Blessing We are blessed by many happy moments honoring motherhood. During this past year we had one first time mother who had a triple blessing. The triplets began life at three pounds each. Infants this tiny are exhausted by the effort it takes to eat. This mother wanted to breastfeed and was determined to pump and increase her milk supply before taking her babies home. Mom was overwhelmed by the demands of these tiny beings with orders to eat every three hours around the clock. She would pump and store milk and then begin the feeding brigade over and over again every three hours. She was amazing and, when on the third day she was transferred, she had several nurses taking turns to help her maintain this feeding ritual so the triplets could mature, gain weight, get stronger and go home at a healthy weight. This family-centered approach nurtured this mom with the needed encouragement of her so named “unit angels.” She learned what it

meant to value family, the NICU way. She went home two weeks later breastfeeding with three amazing, thriving infants. Professional Growth Poster and Podium Presentations This year at the 30th Graven’s Conference, 30 scholarships were sponsored by Dr. Rayleen Phillips through her foundation Small Beginnings Bright Futures. Dr. Phillips highly values the contributions of nurses and she invests in their professional growth. As a result of these scholarships: • NICU nurses submitted several posters to national conferences. Three posters were presented at the 30th Graven’s Conference in Florida. Three posters were presented at the National Association of Neonatal Nurses in Palm Springs. A graduate poster was presented at National Advanced Practice Neonatal Nurses Conference in Hawaii. At the LLU Research Conference, a NICU EBP poster took the first place award. Podium presentations were selected at regional and national conferences including Canadian Association of Neonatal Nurses (ICANN), National Association of Neonatal Nurses (NANN) and One Conference.

Additionally, in the NICU: • NICU mentors and precepts many new students from nursing schools throughout California. • This year we graduated 19 NICU RN residents and two externs. • Hosted He Biyun (Hope), a NICU nurse from ZU Children’s Hospital, China, for two months. TotalCare Birthing Center Nurses Change Lives One Stitch at a Time Gretchen Perkic, RN Although the art of nursing has changed, caring has not. Blessedly, the spirit of nursing … its core and essence … still lives on, though sometimes it’s muffled in the hustle and bustle of shifts. One exquisite example of continuing nursing’s espirit de corps is the TotalCare Birthing Center (TCBC) Christmas stocking party. The idea of presenting postpartum mothers with Christmas stockings in the TotalCare Birth Center dates back to around 1992. Large red stockings with white trimmings were handcrafted by our nurses, embellishing huge felt pieces together, so every baby born during the holiday season could be tucked into them and sent home with their proud parents. The Christmas stockings are enormous stockings,

like ones hanging from mantles, but large enough for an infant’s body to be placed inside of them. Continuing Christ’s message of giving, they are lovingly presented to moms and babies during the Christmas season, all photo op ready. The event was either held in one of the nurses’ homes or on the unit. Staff was excited to join the camaraderie with fellow staff in celebrating the season of Christmas by making stockings and fellowshipping together. Last year, registered nurses Laurie Vonch and Nan-Shih Lee organized nurses, with their sewing machines, to spend a day in our TCBC conference room joyfully making 100 stockings for the newborns. On Saturday, June 10, 2017, the group moved to Redlands Sewing Center, where a band of the sewing center staff and community volunteers, along with Nan-Shih and Laurie, produced 200 magnificent stockings which were handed out to babies born in the two weeks leading up to Christmas. When passing the stockings out to new parents, I have witnessed surprise, gratitude, delight and appreciation from the parents, making the effort, time and dedication it took to sew the lovely stockings well worth it. Florence Nightingale’s spirit of care and kindness still roams the halls of LLUCH. Not only does she carry her lamp, but now she wheels a sewing machine, as nurses know the heart is always the highest healer.

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Nursing Certification Journey National nursing organizations across the country have developed certification programs as a mark of clinical excellence. When an RN achieves national certification in her/his specialty area “it demonstrates to patients, employers and the public that a nurse’s knowledge, skills and abilities meet rigorous national standards – and reflects a deep commitment to patient safety” (aacn. org/certification). Here at LLUCH we recognize the importance of clinical expertise, pursuit of ongoing professional development and the link between national certifications and improved patient outcomes. Therefore we have committed to promoting national certifications throughout our hospital. Here is the journey of two units: For pediatric critical care nurses, the gold standard for certification is the American Association of Critical Care Nurses CCRNPediatric certification. This is a highly sought after certification with comprehensive requirements. The CCRN requires passing a very challenging exam. In order to maintain certification, the CCRN must complete a minimum of 100 continuing education recognition points every three years. For the PICU, it has been a journey over time to build a culture that values and celebrates certification. Early promotion steps included introducing certification at staff meetings,

providing study resources, tying into annual goals and adding to the PICU RN resident mentor meetings. Over the past few years, nurses have been challenged by the “Who’s Next?” motto developed by day shift charge nurse Jamie Hambly, RN, BSN, CCRN. Whenever a nurse passes the certification exam, unit leaders hightlight this important accomplishment through celebratory emails and social media posts.

“National nursing organizations across the country have developed certification programs as a mark of clinical excellence.” We also partnered with our sister unit the Pediatric Cardiac ICU in this venture. Strategies included providing “Let’s Get Certified” bi-weekly emails over several months that provided study guidance, monthly email questions, easy access at nursing stations to practice question books and hosting a review class. So far in 2017, the PICU has celebrated 16 new pediatric CCRN certified nurses. This brings their total to 34 CCRNs.

Acute care pediatrics (ACP) and staff development collaborated with Pediatric Nursing Certification Board (PNCB) to offer the no-pass no-pay program to our nursing staff as a way for them to earn their CPN certification. Our unit is encouraging RNs to become certified pediatric nurses because it demonstrates that they have an expertise in our field. It also provides the nurse a professional recognition and helps our organization with Magnet status. Nurses get two attempts to pass the CPN exam, and if they do not pass on either attempt, PNCB absorbs the failed exam fees. In 2016, we had ten nurses use the no-pass no-pay to obtain their CPN certifications. Our ACP charge nurse, Tami, put together a two day CPN review course for which 35 RN signed-up for. We currently have 17 nurses who have passed and received their CPN.

Award and Recognitions The Leapfrog Group The Leapfrog Group on Thursday, December 7, 2017, presented its Top Children’s hospital 2017 award to LLUCH — the only children’s hospital in the western United States and one of only 10 in the country to take home this honor from Leapfrog, an independent hospital watchdog organization.

2017 NURSING ANNUAL REPORT

Circle of Excellence Award

Hometown Hero Award

Michele Wilson, the pediatric intensive care clinical nurse specialist, was awarded the American Association of Critical-Care Nurses Circle of Excellence award in May 2017. Recipients of this award must demonstrate promotion of patient-centered excellence, be a strong mentor and influencer in their organization, have strong collaborative and communication skills, be transformational thinkers in order to tackle challenges and remove barriers to excellent patient care, and exhibit visible results that validate their organizational impact (American Association of Critical Care Nurses, 2017).

Every day, the stories of children receiving lifesaving care at LLUCH inspire Alane Allbee, a charge nurse. “I did not go into nursing only to be a nurse,” says Alane. “I went into nursing to work with children and make a difference for them.” As she met patients in LLUCH’s adolescent, pediatric oncology and infusion units who were facing financial challenges, Alane realized they and their families would not be able to celebrate Christmas. Every year for more than 25 years, Alane and the entire Spirit of Christmas team work on the project. They identify families to include in Spirit of Christmas and invite them to complete a questionnaire so they can personalize their gifts. When the gifts are delivered, the children are filled with joy. In addition to gifts, the families also receive groceries and gas cards.

Alane shares our passion for children and has inspired many others to help enrich the quality of life of families throughout the Inland Empire. It is our honor to recognize Alane Allbee with the 2016 Hometown Hero Award at the 24th Annual Foundation Storybook Gala on Thursday, February 16, 2017.

This year the AACN bestowed this award on only 25 nurses. This coveted award distinguishes caregivers like Michele and represents our institutional value of excellence to the highest degree. AACN President Clareen Wiencek, PhD, RN, ACHPN, ACNP, says of these recipients: “These health care professionals exemplify why AACN is a community of exceptional nurses. Their efforts are transforming health care and shaping the future of nursing practice, within their units, in the classroom and throughout their organizations and their communities … What nurses do matters at every level, and I am proud to recognize the circle of excellence recipients for being bold and relentless in driving change” (American Association of Critical-Care Nurses, 2017). During the award presentation, at the AACN National Teaching Institute and Critical Care Exposition, Michele shared her legacy statement with the over 6,000 ICU nurses in attendance. “As a clinical nurse specialist, I am committed to guiding the interdisciplinary team toward excellence in collaborative teamwork, evidence based practice, patient and family centered care.”

Loma Linda University Behavioral Medicine Center

Deviyanti Mangunsong Executive Director

Jeevaka Weerasinghe Executive Director

Tony Dharmara Director

Paula Herrera Director

“I have seen our nurses reach out to these children, into the depths of their despair and anguish, and completely turn situations around by providing a living example of Christ’s love to them.”

2017 NURSING ANNUAL REPORT

For 2017, LLUBMC was recognized by Modern Healthcare magazine as one of the best organizations to work for. This was a result of surveys completed by employees of the LLUBMC. These results correlate with our Gallup staff engagement scores where we demonstrated an increase from 4.09 to 4.41 out of 5. Every day at LLUBMC on the child unit we treat patients starting from the age of four to 13 years. One of the more common reasons for admission to the inpatient child unit is intermittent explosive disorders, as well as other aggressive behaviors. We are continuously looking at methods and tools to provide better outcomes for our patients, this year has been no different. Below are the actual tools we began implementing at the end of August as part of our evidence-based practice project. • Therapeutic scripting: series of open-ended questions for nurses to use when a child is escalating. • Stress ball: patient uses this to calm anxiety and create mindfulness. • Coloring book: 20 pages of therapeutic quotes or guidelines with pictures to coincide with the message. • Punching bag: it is colorful, cushiony and better to hit an object than a person.

It is our hope that through the implementation of these methods we will see a decrease in aggressive behaviors, seclusion, restraints and the need for emergency medications. We will also continue to collect data on the outcome of these methods and measure our success and/or see where we need to improve. In our adult population we have implemented new and exciting evidence-based practices. On the geriatric unit we implemented the practice of aromatherapy to decrease falls, anxiety, sundowner’s syndrome, enhance quality of sleep and reduce the need for medications given as needed for sleep. Research shows that the most effective aroma is citrus lemon in decreasing situations such as the ones mentioned. We utilize diffusers throughout the unit and dayroom 24 hours a day, seven days a week. Every four hours the staff refills the diffusers to maintain optimum effectiveness. Not only has this shown to lessen patient’s anxiety, but also has created a calming atmosphere during visiting time. This project began in January of 2016 and to our delight the data we have collected reflected what we had hoped for: a decrease in the number of falls and as needed medications. Implementation of EBPs cannot be done successfully without the hard work and diligence of nurses who are committed to providing patients with the most current

measures of care. Through nurses’ engagement with EBPs and their implementation, we can continue to improve patient care and outcomes. At LLUBMC there is no shortage of amazing and wonderful nurses. Here is an impact nursing story to illustrate. Daisy Award Honoree Joshua Masih, RN Working on the adolescent unit, I have seen many children come through our doors for treatment and I have had the privilege of seeing our staff in action. I have seen our nurses reach out to these children, into the depths of their despair and anguish, and completely turn situations around by providing a living example of Christ’s love to them, as beacons of hope during troubling times. I would like to share an account which involved a psychiatric adolescent RN, Joshua Masih. A patient was admitted after a suicide attempt. Her intention was to end her life and her suffering. This was a very serious attempt, the patient had jumped in front of a moving vehicle. She was hit by the car and had sustained multiple injuries requiring medical hospitalization for several days. Upon arrival to the LLUBMC she was covered with bruises from head to toe, she was still in pain physically, emotionally and spiritually. The patient walked onto the unit looking down at the ground, hiding behind the

hair covering the front of her face. She made no eye contact with staff. The patient sat down in the hallway and did not move. She did not look up as Josh introduced himself to her; she appeared frozen, like a statue, mumbling a quiet response only when she had to. As Josh began the assessment, the patient stated that she felt empty, and had no purpose in life. She did not want to live any longer and felt there was no reason to. Josh spoke to her calmly and soothingly about how God had created her for a purpose and that He had plans for her and loves her. Josh encouraged her to check out the book “Purpose Driven Life” by Rick Warren. The next time Josh was at work, the patient approached Josh and said she wanted to show him something. She ran to her room and returned with the book, “Purpose Driven Life” in her hands and a big smile that lit up her face. I heard her tell Josh that she was beginning to find hope and she was realizing that God did create her for a purpose. I witnessed the joy on Josh’s face as he shared verses with her and they prayed together. Josh was overjoyed by the progress the patient was making. This experience was very uplifting to our team. We were reminded of the gift our hospital’s motto, “to make man whole”, is to the community and of the Lord’s promise to us as a people, “For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you hope and a future.” Jeremiah 29:11.

Months later, Josh updated our team as he had received a text message from one of his friends. Josh learned via the text, a local school was celebrating National Suicide Awareness Day. As part of the celebration the principal read stories written by students outlining how they had personally overcome depression and suicidal thoughts. One of the stories read that day was written by Josh’s former patient, she mentioned the LLUBMC and Josh by name. She recounted how Josh had encouraged her during the lowest moments of her life, she then went on to illustrate how she has now found purpose and hope in a life with Christ. The care this patient received here affected not only her life, but the lives of those who heard her story. Loma Linda University Behavioral Medicine Center Awards Jeevaka Weerasinghe, RN, Patient Care Director Jeevaka Weerasinghe presented a poster at the 2017 Association of California Nurse Leaders in Anaheim, California, on his leadership project entitled, “Engagement Equals Excellence.” The purpose of his project was to improve staff engagement. Using the Gallup Q12 Employee Engagement Survey results from the adult services behavioral health inpatient department, that consists of a 12 bed geriatric unit, 18 bed adult unit and an 18 bed chemical dependency unit, Jeevaka sought to measure changes in staff engagement.

The practice changes that were implemented to improve staff engagement took our organizational mission and values into consideration. These practice changes included: • Administrative charge nurses implemented one-to-one meetings with their frontline staff at monthly intervals. • Quarterly department meeting agenda items were revised to include upcoming changes for discussion and feedback. • Peer-to-peer in-service sessions on evidence based practice topics. • Quarterly staff engagement and celebration meetings to review success. • Quarterly leadership training. • Frontline staff opinion board in staff lounge. • Consistent CNO rounding on all shifts and units. • Town hall meetings brought to staff meetings. The outcomes of this project revealed a significant increase in the Gallup Q12 Employee Engagement Survey. The department roll-up score moved from 3.83 to 4.10 (2015) and from 4.10 to 4.53 (2016) while the direct report score moved from 4.55 to 4.93 (2015) and from 4.93 to 5.00 (2016).

2017 NURSING ANNUAL REPORT

“She was beginning to find hope and she was realizing that God did create her for a purpose.”

Loma Linda University Medical Center – Murrieta Dear Colleagues, As I reflect on this past year, LLUMC – M has been filled with both challenges and growth. First and foremost, our top goal remains steadfast to deliver the highest quality nursing care to our patients. To achieve improved outcomes, our departments consistently work together while focusing on our mission, vision and values. Our team has been working on a number of initiatives. Here are some of our accomplishments: • Improving our ED and inpatient throughput. To better meet the demands of over 45,000 patients per year, our new flex care zones were opened in our emergency department. This process quickly reduced the wait times and increased our efficiencies. There have been reductions in ED door-to-provider times, left without being seen percentages and outpatient length of stay.

“Our nurses are talented, hardworking and caring. Our departments consistently work together while focusing on our mission, vision and values.”

• Earned the Get With the Guidelines – Stroke Silver Plus Award. • Our cardiovascular and stroke team provided community outreach by holding events to promote education and training, to include: CPR training in local schools.

2017 NURSING ANNUAL REPORT

Cardiac rehabilitation attended local city chamber events and health fairs to promote education and provide screenings.

• We are scheduled to open a Level II NICU. Construction was completed in August. The grand opening will be held once CDPH licensing is complete.

The first heart conference, which featured the mayor of Temecula as our keynote speaker, offered physician education, booths and a healthy cooking demonstration.

• We held two successful RN and PCA open house hiring events during the months of February and August. We were able to welcome 37 RNs and PCAs to our team.

The first annual stroke awareness and prevention community event. Quarterly “Living Well” lecture series, which featured education on atrial fibrillation and stroke. On Saturday, May 6, we chaired the Southwest Riverside County American Heart Association Heart Walk, which raised a record-breaking amount of over $180,000. • Leapfrog Grade B. • Began our journey toward Magnet. We are currently working with the coordinators and conducting our degree and national certification gap analysis. • The first annual baby conference was held on Sunday, August 27. This event provided support and education for new and expectant mothers. There were speakers, exhibitors, opportunity drawings and giveaways.

• We are the second largest ST elevation myocardial infarction (STEMI) receiving center in the entire County of Riverside. • We partnered with LLUSN. 29 RNs signed up for the RN to BS program. LLUSN will be on the Murrieta campus to provide monthly support for the RN to BS students. Future Goals • We are working with the director of nursing research to start evidence-based practice teams throughout LLUMC – M. • We are excited about the future initiatives as we plan on rolling out the Clinical Ladder in 2018. Our nurses will have the chance to work toward becoming a clinical nurse-C or D. • Form professional governance committees. • We are working toward Get with the Guidelines, a Stroke Gold Quality Achievement award.

I am humbled and thankful to work with such a dedicated and wonderful patient care team. Our nurses are talented, hardworking and caring. The team is excited about the support we have received from the LLUH system and look forward to focusing on our strategic and longterm goals. “For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future.” Jeremiah 29:11. Sincerely,

Linda Soubirous, MSN, MPA, RN

Honored by the American Heart Association During our first year of becoming a Primary Stroke Center, LLUMC – M received the highest possible recognition from the American Heart Association (AHA) Get with the Guidelines - Stroke, the Silver Plus award. According to the AHA, the Silver Plus quality award is an advanced level of recognition that acknowledges specific hospitals for consistently complying with quality measures. Because of this honor, LLUMC – M will be honored at national recognition events during the International Stroke Conference and listed by name in advertisements that appear annually in the journal Stroke and in the “Best Hospitals” issue of U.S. News and World Report. Cardiovascular Services Recognized Nationally In 2014, LLUMC – M cardiovascular services became a national show site for Siemens Medical Solutions. We were chosen by Siemens because they recognized our high degree of effectiveness in using their system. Hospitals from all over the country are invited by Siemens to tour our facility and observe our use of the system and workflow. Every time we conduct a site visit we receive funds that benefit the entire hospital.

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Loma Linda University Medical Center â&#x20AC;&#x201C; Murrieta

Linda Soubirous Chief Nursing Officer

Rene Tovar Executive Director

Angie Camacho Executive Director

Kristin Butler Manager

Tiera Jacobs Director

Jennifer Ross Manager

Sheri Pentz Director

Elisa Papell Director

Kate Jensen Manager

Jeremy Fleenor Manager

Teresa Peters Manager

Clinics

“… because of all the strategies he learned through the education program at the Diabetes Treatment Center, he has been empowered to live a healthy lifestyle.”

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Diabetes Clinic Diabetes is one of the most prevalent chronic diseases affecting Americans and the worldwide population. The Centers for Disease Control and Prevention (CDC) indicates that 29.1 million people or 9.3 percent of the population of the United States have diabetes, with 27.8 percent of those being undiagnosed. Untreated diabetes can lead to devastating complications. In an effort to decrease the burden of diabetes, the LLUH Diabetes Treatment Center (DTC) offers a variety of programs to help individuals with diabetes or prediabetes manage their blood sugar and meet their health goals. An experienced team of nurses and a dietitian certified in diabetes education teach a series of classes to guide the patients on their personal journeys to manage, and in some cases even reverse their diabetes. They utilize behavioral change techniques to motivate their patients to take charge of their diabetes management, and provide ongoing encouragement through a free monthly support group. The support groups include guest speakers and a healthy recipe that is shared at the end of each meeting to encourage the participants to cook more of their meals. More than simply sharing knowledge, this is an opportunity for patients to interact with each other, share experiences and develop friendships.

This unique model allows the nurses to serve on the inpatient side by initiating bedside education on the most urgent topics of diabetes management, while encouraging those patients to attend classes at the DTC in the outpatient setting. This is a critical component in the efforts to prevent hospital readmission and provide quality and consistent care through the health care continuum. The DTC has had successful outcomes from a hospitalized patient with an A1C of 13.8 percent. Diabetes nurse educators went to the hospital and saw the patient with his family at the bedside, teaching survival skills to manage his diabetes once discharged, until the patient could come to receive outpatient diabetes self-management education. A few weeks later, the patient attended the class series at the DTC and upon completion of classes two months later, his A1C had dropped to 5.8 percent. The patient stated that because of all the strategies he learned through the education program at the Diabetes Treatment Center, he has been empowered to live a healthy lifestyle. His A1C 6 months after the initial visit was 5.6 percent, which is at a normal, non-diabetic level. Cardiology Clinic New technology can be exciting and daunting at the same time. This has been the experience of the heart failure nurse practitioners, Sharon Fabbri and Denise Petersen, over the last

year. LLUMC has started implanting the CardioMEMS pulmonary artery pressure sensor as of June 30, 2016, and there are 16 active patients being monitored. The device was studied during the CHAMPION research study and it was found to decrease hospitalization and mortality in heart failure patients. Patients who have been in the hospital within the past year and have symptoms of heart failure with minimum exertion qualify for the procedure. The sensor is implanted during a right heart catheterization and patients may go home the same day. The patients take home a specialized pillow that they lay on for less than a minute each day. The reading is then uploaded by 3G technology and is available for the NPs to review via a secure website. The goal is to intervene as pressures start to rise before the patient may start having symptoms of shortness of breath, fatigue or swelling. The NPs had to learn the nuances of the pressure readings, how to adjust medications according to the values and to trust the numbers in the absence of changes in symptoms. Only one patient has been admitted for heart failure symptoms since this program was initiated and several patients have had an improvement in their symptoms. The program has been viewed a success and will continue being utilized at LLUMC.

Institutes

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Cancer Institute Desperately Seeking Oncology Nurses Lexine Thall, MN, RN-BC, AOCN and Kristina Chase, BSN, RN, OCN One of the most challenging issues in health care is the ongoing balancing act of staffing and retention. For specialty areas, such as oncology, staffing presents an even more difficult challenge. Finding those perfectly qualified individuals with all the right experience to fill open positions can be a taxing, timeconsuming task. As a result, cancer programs may find themselves dealing with lengthy vacancies, which can cause serious strains on a growing clinic and may lead to an unhappy environment for nurses and patients. When our cancer program encountered this understaffing dilemma, chemotherapy skilled and oncology experienced (CS-OE) RNs in our cancer center began facing increased workloads, which put them at risk for potential burn out, vulnerability to making errors and causing longer wait times for patients. Our cancer program leadership team had to think outside of the box and create a road map to alleviate some of these staffing strains. An analysis of appointment types and RN skill level needed for each visit type revealed that 40 percent of our supportive care therapies (e.g., hydration, blood transfusions) did not

require a CS-OE RN. Given this information, we decided to pilot a program that would fill RN vacancies with experienced non-oncology nurses and create a pathway for these RNs to attain the Oncology Nursing Society (ONS) Chemotherapy/Oncology Nursing Certification Corporation (ONCC) Biotherapy Certificate. Our aim was to provide a mentorship program in conjunction with vetted education tools to develop these RNs professionally and alleviate our staffing crisis. The pilot program launched in 2014, and to date, 17 nurses have been accepted into the mentoring program. All RNs who opted to pursue the ONS/ ONCC Chemotherapy Biotherapy Certificate, seven of seven, have attained their goal and 86 percent, six of seven, of the RNs who attained this certification have remained with our organization. Our mentorship program has drastically decreased the length of time we have unfilled RN positions posted—from an average of 113 days down to 29 days. It has also given many nurses an opportunity to gain focused experience in a specialty area for which many employers may not be willing to bear the educational costs. In addition to the benefit for the non-oncology nurse, the program has provided professional satisfaction and role expansion for the CS-OE RN mentors. A winwin for all parties involved.

“Our cancer program leadership team had to learn to think outside of the box and create a roadmap.”

Our mentorship program has been recognized as follows in 2017. First, in a poster presentation at the ONS Annual Congress in May 2017 in Denver, Colorado. Second, in the recognition as a 2017 Innovator Award winner for the Association of Community Cancer Centers (ACCC) to be awarded in at the ACCC 34th National Oncology Conference in October 2017 in Nashville, Tennessee. Perinatal Institute Our quality improvement has centered around the staff nurse knowledge of research projects, getting samples and the LLU Institutional Review Board (IRB). Other measures include the compilation of the aggregate list of research projects for third floor investigators and communication during research rounds principal investigator monthly meetings. Care for mothers

and newborns spans the Perinatal Institute. One example is an infant who was part of our program that focuses on very low birth weight infants and fortified human milk. The mother, who was cared for on unit 3100, required an urgent C-section and then received postnatal care on 3800. As she transitioned throughout the institute we maintained the continuity of care and breastfeeding education. The perinatal institute research area is engaged with a widespread community. It is part of the Global Alliance to Prevent Prematurity and Stillbirth, sending research samples across the United States. We are involved with two funded studies that started out as investigator-initiated pilot studies here at LLUCH. One study estimating the gestational age via smartphone is now funded by the Gates Foundation and Research Triangle Institute in North Carolina. The second study is the PREMOD study, which is funded by the NIH, and began as a collaborative study with Sharp San Diego. This office also helps disseminate research and generalizable knowledge through support of posters, abstracts and publications.

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International Mission Trips Global Health Institute Pediatric Oncology Nurses Educate Nursing Staff in Hong Kong DonaJayne Potts For the third time in the last five years, the Global Health Institute sent two pediatric nurse specialists from LLUCH to the vibrant and densely populated urban center of southeastern China, Kowloon, Hong Kong to provide clinical expertise, mentoring and training to health care professionals in need of specialized consultants. Kimberly Johns, RN, DNP, PCNS-BC, CPON, a clinical nurse specialist in pediatric oncology and Jacki Blake, RN, MSN, CPON, patient care director, are both certified educators by the Association of Pediatric Hematology/Oncology Nurses (APHON). APHON is a professional organization started in 1974, for pediatric hematology/oncology nurses and professionals. Its members are dedicated to promoting optimal nursing care for children, adolescents and young adults with cancer and blood disorders, along with their families. Hong Kong’s Hospital Authority, a statutory body comprised of 42 public hospitals and institutions, 48 specialist outpatient clinics and 73 general outpatient clinics, invited these nurses to present an intensive two-day course entitled “Pediatric Chemotherapy and Biotherapy Provider Course.” The course is

designed to provide pediatric nurses with the knowledge base needed to safely care for children and adolescents receiving chemotherapy or biotherapy. Time spent in lecture and testing is anticipated to equip these health care professionals with new treatment skills that in turn can be shared within an institution’s oncology department. On January 17, 2017, 20 nurses successfully completed the training and post-course examination required by APHON and each received a provider card valid for two years. Since 2012, under the tutelage of Johns and Blake, over 100 pediatric intensive care, general pediatrics and pediatric oncology nurses in Hong Kong have been certified by APHON. “We are passionate about connecting globally with other pediatric oncology nurses,” said Blake. “It’s fascinating to know that you can go across the world and nurses have similar treatment regimens and deal with the same patient struggles.” “Teaching this course provides us with an opportunity to collectively share our experience. It has allowed us to become a community,” Johns adds. “We have formed an intercontinental network of support.”

Kimberly Johns RN, DNP, PCNS-BC, CPON and Jacki Blake, RN, MSN, CPON, (center) among course participants.

One of the registered pediatric nurses displays her colorful drawing during a creative interactive exercise.

Loma Linda University Health Nursing Staff Mentors One of Malawi’s First Intensive Care Unit Nurses African Nurse Takes Part in the International Professional Program to Improve Patient Care in Malawi DonaJayne Potts Felix Batson, RN, a visiting ICU nurse from Blantyre Adventist Hospital, Loma Linda University Global Campus-Malawi, experienced firsthand how lives can be saved with updated basic life support training. During a rotation on the medical intensive care unit at LLUMC, a woman collapsed, suffering from a cardiac arrest. Batson witnessed a team of nurses spring into action and perform a one-hour resuscitation on the victim. “They were able to stabilize the patient and I left the hospital that day knowing how to save a life,” he said. In the African culture of medicine, doctors typically take the lead in responding to a code. Here at LLUH the nurses start life support immediately. Baston said, “I have been empowered, I will return to my country with great confidence, knowing that I too can save lives.” During his mentorship, Batson received a variety of life support training classes including basic life aupport (BLS), basic arrhythmia recognition and treatment (BART), advanced cardiovascular life aupport (ACLS) and stroke

assessment and management using the stroke risk assessment tool (SRAT). Debbie Nkumba, RN, MSN, CNS, critical care educator at the LLUH staff development department, was recently reunited with Batson, a nurse she taught in Malawi over six years ago. In 2011, Nkumba had returned to her country of origin, Malawi, Africa, to educate critical care nurses who were to staff one of the first and most advanced intensive care units in the country, and Batson was one of her first students in training. Nkumba, a critical care nurse and educator for the past 15 years at LLUH, was the instructor for a BART class attended by a group of visiting international health care professionals this past July. She immediately recognized Batson as one of the attendees and was eager to see his progress. “I saw significant growth in Batson, his critical thinking and thought process skills have greatly improved,” says Nkumba. “He did well on all of his exams and seems more confident in his nursing abilities,” she said. Since the inception of the International Professional Development Program in 2013, staff members of LLUH have mentored 749 international visiting professionals from 20 different countries. “Loma Linda University Health is wonderful,” Batson exclaims. “The staff is so warm and welcoming and they do not mind explaining medical processes in detail. They want to make sure

we truly understand,” he said. Batson was also impressed with how technology can impact the ability to identify and treat diseases among intensive care patients. “At home we have to just guess if someone has epilepsy, but with an electroencephalogram (EEG), a test that measures and records the electrical activity of your brain, you can see any abnormal brain activity,” he said. He was particularly excited about seeing a dialysis machine. “In our hospital, we have learned only theoretically about dialysis, to see a patient being treated by this machine was absolutely fascinating,” he said. Getting a chance to see innovative technology wasn’t the only highlight of his experience. “Loma Linda University Health has changed how I will care for patients,” Batson said. “I know how to better communicate and I will provide them with a higher level of hygiene and personal care,” he said. Derek Hidalgo, RN, BSN, MBA, director of patient care MICU/SICU/neurology, believes that his nursing staff benefitted in many ways too from Batson’s visit. “It was amazing to have his perspective, sometimes our nurses can forget what nursing is like outside the unit,” Hidalgo said. “We are so blessed to have emerging medical technology, advanced health care systems and a team-oriented working environment which allows us to provide our patients with the best care possible.”

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Batson is eager to share what he learned and observed at LLUH with his peers and colleagues in Malawi. “Nurses at LLUMC are dedicated and highly motivated, I hope sharing what I have experienced will inspire my fellow staff, just as I have been inspired,” he said. “I will return home with a stronger sense of what a nurse is and what they can do.”

Blantyre Adventist Hospital in Malawi’s second largest city has 40 patient beds and houses major medical specialties.

Debbie Nkumba, RN, MSN, CNS, (far right) instructs a group of nurses at Blantyre Adventist Hospital, Malawi on critical care in 2011.

Felix Batson, RN and Derek Hidalgo,RN, BSN, MBA

Unit 4700 MICU nurse, Angelica Llamas, (center left) among other SIMS volunteers, overlooking the valley of La Misiรณn, Baja California, Mexico.

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Angelica Llamas, a LLUMC nurse for the past four years, provides medical triage and health education to a Panamanian villager in need.

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International Volunteer Experience Impacts MICU Nurse DonaJayne Potts The 87-year old Panamanian man is hunched over from decades of machete use. Even in his old age he continues to clear weeds and bushes from a local banana plantation to support his family. He is a short sturdy man with leatherybrown, deeply-wrinkled skin from a lifetime spent in the tropical sun. Arturo is among a group of indigenous people from Bocas Del Torro, one of the poorest regions in Panama, who traveled to a small school on the outskirts of town to be seen by one of the visiting medical missionaries. Angelica Llamas, RN, BSN, CCRN, a medical intensive care unit 4700 nurse at LLUMC and mission trip volunteer, addressed Arturo’s complaints of body aches, mouth pain and vision problems. After teaching him about proper body mechanics and dental hygiene, it struck Llamas that he might also benefit from a pair of sunglasses—she hoped to protect eyes, lessening the risk of cataracts. Llamas was able to find a pair amongst her fellow volunteers and when she handed Arturo the glasses, a wide toothless smile spread across his face. “He lit up like a Christmas tree and his only remaining tooth was like the shining yellow star on top … he was so grateful,” Llamas said. “That was

when I realized that even the smallest thing can make a huge difference in someone’s life,” she said. Because of her personal mission experience in Panama, Llamas returned to Loma Linda with the desire to continue to serve abroad on short-term mission trips through her home institution. In late August of 2017, she joined a group of 25 physician assistant (PA) students on a weekend mission trip to La Misión, Baja California, Mexico, organized by Loma Linda University Health Students for International Mission Service (SIMS). The group made up of PA students, LLU faculty and LLUH staff were summoned to northern Mexico by a call for help from physician assistant alumnus Sarah Mayer, MPA, PA-C. Upon graduation in 2006, Mayer decided to complete her six-month clinical rotation internationally in La Misión, and after nine years she is still serving there. Health care and health education in La Misión is in high demand, in part due to its rural location. Inhabitants must travel more than 40 miles, typically by foot, to be seen by a medical professional at a hospital. Since 2016, SIMS has partnered with Mayer, to organize short-term student mission trips to provide health education, and medical and dental care to residents of La Misión. During SIMS’s most recent trip to Mexico, Llamas served not

only as a translator, but was able to evaluate and administer care to over 80 patients. In an environment where medical resources were limited, “I was thankful to have the critical thinking skills I learned by working on the MICU unit,” she said. Llamas plans to continue to serve internationally and believes that serving abroad has made her a better nurse. “I will be more effective in helping people through illness towards wellness,” she said. “I now understand that even something small can make a positive change in a patient’s life, no matter how little or much they have.”

We cannot let a fear of failure, a fear of comparison or a fear of judgment stop us from doing the things that will make us great. Therefore we must risk, we must lead with our hearts and minds as we leave footprints in the sands of time.

MANY STRENGTHS. ONE MISSION. A Seventh-day Adventist Organization | LLUHEALTH.ORG