2013-14
Year!
Rex Healthcare Nursing Annual Report
An
Fron the Chief Nursing Officer
Dear Rex Friends and Colleagues, If you were to ask anyone across our organization what phrase best describes 2014 the answer would most likely be, “An Epic Year.” Certainly, the implementation of Epic@UNC as our new electronic health record was a big part of 2014, but so much more has gone into making 2014, “An Epic Year.” On May 1, 2014, we celebrated the 120th anniversary of our bringing the very best in health care services to the citizens of Wake and surrounding counties. It is such a privilege to be continuing that legacy of commitment and caring to these growing communities.
UNC
At the same time of the Epic@UNC implementation, we also launched a new Interdisciplinary Care Plan one patient ID, one problem list, one medication list, one bill (CPM) and Bar Code Medication Administration (BCMA). Our nursing team achieved and sustained 96 percent compliance with patient scanning within just two weeks of our going live. Epic@UNC, CPM and BCMA had an enormous impact on our nursing practice, moving us toward increased charting at the bedside, changing many aspects of patient flow through our health care system, improving communication across all of our disciplines and enhancing the safety of our medication administration practices. The Epic Corporation reported that the simultaneous launch of Rex Healthcare, University of North Carolina Medical Center and Physician Practices, referred to as the “Big Bang,” was possibly the best they To make a positive had ever experienced. I want you to know that this was difference in the lives of because of your dedication and commitment to completing training to ensure we were ready to care for patients on our patients every day. day one of the go-live. I am so very proud of our nursing team for embracing this new technology, for your resilience during those challenging days of implementation and, most importantly, for your unwavering commitment to ensure we continue to provide compassionate, connected care to every patient and their families.
OUR MISSION
Throughout this Epic Year our nursing team has continued to keep our patients and families at the center of everything we do by delivering excellence in quality and service. For the second year in a row Rex Healthcare received an “A” Rating by the Leapfrog Group. In 2014 we completed a highly successful Joint Commission Accreditation Survey and were also accredited by The Society of Chest Pain as a Level IV Chest Pain Center. Both agencies commended our nursing team for best practices. Our nurses are truly bringing national attention to Rex Healthcare.
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We have made a significant commitment to the advancement of our professional practice. I have been so impressed by our nurses’ commitment to achieve professional certification and am delighted that we have been able to help so many achieve that certification through the “Fail Safe” program. Through partnerships with local universities we have been able to make academic study more accessible to our nurses. The Rex Healthcare Foundation has always been a champion for nursing education and has awarded generous scholarships for our nurses who are looking to advance their education. Although we take great pride in our 120-year history of serving our community we are looking toward an even brighter future. In 2017 we will open the new North Carolina Heart and Vascular Hospital. Our nursing team has been at the table in every phase of planning to ensure we are building a state-of-the-art hospital, bringing together a beautiful space, leading edge technology, and an incredible nursing team to provide the very best in cardiac care to our community.
Table of Contents Transformational Leadership . . . . . . . . .
4-5
Structural Empowerment . . . . . .
6-7
Exemplary Professional Practice . . . . . . . . . .
8-17
New Knowledge, Innovations & Improvements . . .
18-21
2014 has been an epic year, and the best is yet to come. Once again, I must say how very proud I am to serve such an incredible nursing team. Words cannot express my appreciation and admiration for all that you do “to make a positive difference in our patient’s lives every day.” Warm regards,
Joel Ray
Joel Ray, MSN, RN, NE-BC Vice President Patient Care Services/Chief Nursing Officer
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Transformational Leadership
From the Nursing Congress I have been honored to serve as Chair of Nursing Congress during this year at Rex and am so proud of the work Rex Nurses have accomplished. It is with excitement and enthusiasm that I invite you to read our 2014 Nursing Annual Report. During fiscal year 2014, the Nursing Congress participated in the first Nursing Strategic Planning Retreat, held at the North Ridge Country Club in April 2014. Under the leadership of our new CNO, Joel Ray, we worked hard to update the Nursing Strategic Plan. We asked each of the Nursing Councils to work on a part of the strategic plan and are very excited to see what we have accomplished. We continue to make progress in advancing nursing education, promoting certification and increasing participation in the shared governance process. This year we will gather again to welcome new members, bring life to fresh ideas and establish a plan of action to use evidence-based practice to improve patient care. I hope you read and enjoy this Nursing Annual Report and are as proud to be a nurse at Rex as I am.
Helene Murphy, BSN, RN Chair, Nursing Congress
Robin Deal Receives Lifetime Achievement Award Robin Deal, RN, perinatal services manager in women’s and children’s services, received the Lifetime Achievement Award for her work in North Carolina on Child Passenger Safety. This award was presented on March 25, 2014 at the BuckleUp Conference at the North Raleigh Hilton. Wayne Goodwin, North Carolina Insurance Commissioner; Robin Deal, BSN, RN, CE, Perinatal Services Manager; Bill Hall, UNC Highway Safety Research Center Occupant Protection Program Manager; and Susan O’Dell, MSN, RN, NC-BC, Director Women’s and Children’s & Specialty Services
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Transformational Leadership
Fail Safe Program Leads to Successful Certifications In October 2013,Vicky Overby, MSN, RN, CMSRN, Medical Surgical Clinical Nurse Specialist, shared information with her nursing director, Helene Zehnder, MSN, RN, NE-BC, PCCN, about the Fail Safe Certification program offered by the Academy of Medical-Surgical Nursing. As the President of the Academy of Medical-Surgical Nurses’ Triangle Chapter,Vicky was familiar with this program and the advantages for hospitals and for clinical nurses. Through the Fail Safe program the Medical-Surgical Nursing Certification Board offers nurses the opportunity to take the certification examination, with no up-front out-of pocket cost to the nurse. The hospital is responsible for paying the certification exam fee after the clinical nurse successfully passes the exam. The nurse has up to two times to pass the exam. Participation in this program was approved by Rex Chief Nursing Officer, Joel Ray, MSN, RN, NE-BC, and the contract was signed in March 2014. On March 10 and 11, 2014, Rex offered an on-site review course to help our nurses prepare for the Medical-Surgical certification exam. Thirty-five nurses participated in this two-day course. During 2014, 31 nurses successfully passed the certification exam and now hold the credential of Certified Medical-Surgical RN (CMSRN). As with all nursing certifications at Rex, the certification fee was paid through the Rex Foundation Nursing Excellence Fund.
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Structural Empowerment
Post-Anesthesia Care Unit (PACU) Nurse Internship Helps Nurses Transition to Permanent Roles The specialty of peri-anesthesia nursing, as with all of nursing, has reached a critical shortage that is posing a crisis in health care. Historically, the practice in schools of nursing has been to strongly encourage graduates to experience medical-surgical nursing during their first year of employment while discouraging those new graduates from going directly into a specialty field. Additionally, seasoned nurses in specialty areas were also hesitant to welcome new graduates into their practice. Nurse residency training programs consistently concentrated on general nursing areas such as critical care and medical-surgical nursing. Specialty areas, like peri-anesthesia nursing, focused on recruiting nurses with at least one year of experience which greatly limited their pool of candidates. In response to a growing need for skilled PACU nurses, the PACU at Rex Healthcare identified the need to provide an opportunity for new graduate nurses to develop their skills and become wellrounded, competent nurses with awareness of their patients, team-members and themselves. Since inception, the PACU has successfully transitioned six graduate nurses into permanent roles. During the past year, the Pre-Op and PACU management team decided to expand their internship program to provide a more in-depth exposure for the new graduate to the basic skills of nursing that they may have obtained if working on a medical-surgical floor. These skills include, but are not limited to, basic assessment of various patient types, interaction with families and physicians, fostering communication, skill development, documentation in the electronic record (Epic@UNC) and opportunities to complete any specialty requirements such as ACLS and PALS. The internship program for the nurse graduate now involves all phases of peri-operative nursing, beginning in the Perioperative Planning Center continuing through to Level II Recovery. As the intern transitions into the PACU area, he or she is enrolled in the Essentials of Critical Care Orientation program with other critical care nurses to enhance their internship experience. We have witnessed many benefits of the new program. Experienced nurses have expressed satisfaction in the opportunity to serve as mentors, to foster insight, identify needed knowledge, and expand growth opportunities for their mentees. As proven by other residency programs, we too have experienced retention of the new graduate nurses and increased our pool of resources. Since we are continually being challenged with finding experienced candidates to fill our vacancies, it is even more important to focus on development of our own pool of competent peri-operative nurses.
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During fiscal year 2014 the number of transfer patients from outside of Wake County began to increase particularly due to the growth of our Heart and Vascular service. This growth necessitated an increase in the services related to getting the patients into beds at Rex. The Transfer Center began in 2012 with one nurse who worked five days a week, eight hours a day and has now expanded to a team of nurses working 24/7 in fiscal year 2014. The Transfer Center is a nurse-led service for Rex Healthcare. Rex has become a tertiary referral center for smaller community hospitals in counties surrounding Wake. Patients come to Rex from Johnston, Franklin, Wilson, Sampson and many others for the advanced care and procedures offered at Rex. In the beginning, an average of 40-50 patients a month were handled by the Transfer Center nurse or the Administrative Coordinator. The growth by the end of fiscal year 2014 was an average of 200-300 patients a month coming to Rex. These patients not only come for the Heart and Vascular programs but many for orthopedics, general medicine, surgery or other service that the small community hospitals cannot provide. The Transfer Center also handles the placement of Behavioral Health patients for appropriate inpatient treatment as well as handling the transfer needs of patients who need to go to UNC CH Medical Center or other hospitals.
Structural Empowerment
Rex Transfer Center Now Operates to 24/7
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Exemplary Professional Practice Late Preterm Infant Committee Works to Optimize Patient Outcomes Late preterm infants are infants born between 34 and 36 6/7 weeks gestation. They represent a unique challenge for health care providers because of their physiologic and developmental immaturity. Historically they have often been assumed to be as robust as their full-term counterparts and, unfortunately because of this, have been cared for in a similar fashion. There is a growing body of research that suggests that despite their often similar appearance to term infants, late preterm infants experience significantly higher rates of morbidity and mortality. Studies have consistently shown that these infants are at a higher risk for feeding difficulty, hypoglycemia, temperature instability, respiratory distress, sepsis, jaundice and readmission to the hospital. The potential for both short- and long-term cognitive, behavioral and developmental problems has also emerged as a threat to the health of the late preterm infant.
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Some of the key changes in policy that have been made are: • Neonatology consult for any infant born between 34 to 36 6/7 weeks gestational age that is admitted to the newborn nursery. • Lactation consult for the mother-baby dyad within 6 hours of delivery and then twice daily until discharged.
Exemplary Professional Practice
Out of these growing concerns, the Late Preterm Infant Committee was created. The committee is a multidisciplinary team comprised of nursery and post-partum nurses, lactation consultants, clinical educators, nursing managers, mid-level providers and a neonatologist, all with the primary goal of optimizing patient outcomes for this vulnerable population. Using evidence-based clinical practice guidelines, such as those established by Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN) and National Perinatal Association, multiple policy changes have been implemented to support this goal.
• At the time of the initial lactation consult, in addition to observing any early breastfeeding attempts, the mother is instructed on the use of the breast pump and hand expression, both of which have been linked to higher maternal milk supplies. • The infant’s first bath is delayed for six hours to encourage early breastfeeding and skin-to-skin contact, which are associated with multiple benefits to both mother and infant. Clinical surveillance of the infant has improved through more frequent nursing assessments and vital signs, as well as regular glucose monitoring of the infant. An evidence-based infant feeding protocol has been implemented to promote adequate infant intake and prevent excess weight loss. Standing orders have been implemented for bilirubin levels at 36 hours of age to detect any early jaundice, as well as a car seat safety test. A “Pea Pod” card has been specially created for the late preterm infant’s crib and mother’s room door to alert all staff to the infant’s fragile nature and increased risks. Plans for future work include developing written parent educational materials for discharge in the form of a booklet which can be personalized by the parents.
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Exemplary Professional Practice
Rex Healthcare Achieves Cycle IV Chest Pain Accreditation In June 2014, Rex Healthcare was re-designated a Chest Pain Center by the Society of Cardiovascular Patient Care (SCPC). Rex Healthcare received its initial Chest Pain Center designation in 2006 and was the first hospital in Wake County to earn this designation. Since then, Rex has successfully been re-designated two more times. Achieving this designation and providing exemplary care to our cardiac patients requires teamwork, which is led by nurses passionate about providing the most advanced care possible. Charles Cheek, BSN, RN, CNML, CCRN, Clinical Manager of the Cardiac Intensive Care Unit (CICU), leads the team which includes Shae Earles, BSN, RN (Emergency Department RN and EMS liaison); Sonya Mangum, BSN, RN (Team Coordinator for CICU); Mariann Lannon, BSN, RN (Cath Lab); Ciera Gowers, BSN, RN (Clinical Manager for Cath Lab); Debra Brown, RN (Quality Coordinator for Heart and Vascular); Janice Laurore, BSN, RN (Clinical Manager for 3West); as well as many staff nurses in the emergency department, cath lab and cardiac inpatient units at Rex. The team is supported by a multidisciplinary group with physician leadership from cardiologists, emergency physicians, hospitalists, intensivists, respiratory therapists and diagnostic services co-workers. The highlight of the work to achieve the Cycle IV accreditation was the team’s development of a “Passthrough Protocol” that facilitates patients passing through the emergency department and straight to the cath lab for procedure to open the vessels in the heart. When patients experience a life-threatening heart attack, the sooner the cardiac artery can be opened, the better chance of saving the heart muscle. The goal is to open the vessel in less than 60 minutes from the time of arrival or from first medical contact. The Rex Chest Pain Team has achieved this goal and was cited by the SCPC surveyors for their exemplary work in providing the most advanced care to the community.
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Early in 2014 preparations for the Epic@UNC go-live were well underway. In order to minimize disruption to patient care, an interdisciplinary team was formed to address patient flow and throughput. This team, led by system Chief Nursing Information Officer Marguerite Williams, MBA, MHA, RN, NE-BC, and Chief Nursing Officer Joel Ray, MSN, RN, NE-BC, wanted to ensure that all co-workers knew the new system’s steps for admission, transfer and discharge of patients from any location. Because there are so many possible scenarios, they knew a one-time class would not be sufficient for teaching co-workers to master the new system. So, the team’s goal was to create a patient flow matrix capable of addressing all situations and serving as a tip sheet for nurses in the moment. Team participants included the directors of nursing, radiology, lab, and heart and vascular; clinical managers from nursing and ancillary areas; members of the core team working on building the system; and Epic experts. Subject matter experts at the front line staff level participated to share their daily workflow and ensure all current activities were addressed.
Exemplary Professional Practice
Team Creates Patient Flow Matrix Prior to Epic Launch
This team met weekly for about eight weeks, working through each patient type and clinical area. In each meeting, the steps to admit, transfer and discharge a patient were put in writing. All the patient flow instructions were organized by originating area so a nurse or other coworker could easily use them from their location. For example, if a nurse in the emergency department had an obstetrical patient who really needed to be in labor and delivery, the nurse would go to the ED section of instructions and select this scenario. He or she would find stepby-step instructions to enter the patient into the computer system, select the appropriate orders and transfer the patient to labor and delivery. The final product of this team’s work was printed, bound into a small booklet, and distributed across the organization. This resource was widely used at go-live and still serves as a tool for new co-workers to the organization.
Susan O’Dell, MSN, RN, NE-BC Director of Women’s, Children’s and Specialty Services
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Exemplary Professional Practice
“Get Up and Go” Initiative Generates Increase in Patient Mobility The nursing staff on 5West recognized that patients should be mobilized earlier in their stay. While researching the literature they found there are complications related to prolonged immobility such as accelerated bone loss, dehydration, malnutrition, delirium, sensory deprivation, isolation, sheering forces on the skin, reduced exercise capacity, reduced muscle strength, incontinence, weakness and potential for continued decline in function after discharge. The “Get Up and Go” Early Mobility Initiative is a nurse-driven protocol to appropriately assess a patient’s readiness for mobility in the Medical-Surgical Acute Care setting. This was chosen so that nurses could assess and mobilize patients earlier without waiting for consults from physical therapy or physician orders. Early mobility interventions can potentially achieve better patient outcomes by supporting physical function, decreasing length of stay and prevention of complications. The “Get Up and Go” Early Mobility was initiated by 5West, a 32-bed Medical-Surgical Acute Care setting. The purpose of this initiative is to promote early mobility, decrease length of stay, follow trends in physical therapy consults for evaluation, and measure instances of times and number of feet ambulated. For the interventions, all staff were educated on the “Get Up and Go” Early Mobility Initiative, appropriate and safe mobility interventions and use of a gait belt. Nurse and nursing assistant champions were identified. These co-workers, along with the 5West physical therapist, helped provide education. Nurses assess all patients at 7 a.m. and 7 p.m. using the “Get Up and Go” test to score the patient. Nurses and nursing assistants (under the direction of the RN) then implement mobility interventions based on the “Get Up and Go” score. If a patient is unable to participate in the mobility assessment, the nurse may consult Physical Therapy for their evaluation and recommendation for treatment. Each patient receives information regarding the importance of mobility for hospitalized patients and the “Get Up and Go” Early Mobility Initiative in their welcome packet. Prior to the initiation of this project, data was collected which revealed only 22 patients were being ambulated with a total of 6,570 feet ambulated. The most recent data shows an increase with 74 patients being ambulated for a total of 27,244 feet.
Description
Score
Intervention Plan
Able to rise in a single movement. No loss of balance with steps.
0
Patient to ambulate three times daily in hallway. Patient in chair for all meals.
Pushes up. Success in one attempt.
1
Ambulate patient two times daily with assistance in hallway and up for all meals.
Multiple attempts, but unsuccessful.
3
Use gait belt. Patient in chair for all meals. Patient can use bedside commode.
Unable to rise without assistance during testing.
4
Patient out of bed at least once a day or bed in chair position. Use mechanical lift to get patient out of bed if unable to stand. See further instructions below.
Exemplary Professional Practice
“Get Up and Go� Test
If your patient scores a 4, RN initiates a physical therapy consult for evaluation of patient.
Length Number of Number of Total of Stay Patients Times Patients Feet Ambulated Ambulated Ambulated Oct 2014 Nov 2014 Dec 2104 Jan 2015 Feb 2015 Mar 2015 Apr 2015
3.49 3.73 3.53 4.2 3.4 3.3 3.5
22 60 51 81 92 93 74
32 161 172 165 237 193 169
6,570 26,161 29,279 21,469 25,796 33,153 27,244
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Exemplary Professional Practice
Hundreds Benefit from Hands-Only CPR Training In 2014, after receiving the Chest Pain Accreditation, the staff on 3West decided to start a “hands only CPR� training for patients and their families. Janice Laurore, BSN, RN, 3West clinical manager, learned about a grant opportunity from the RACE CARS initiative that could help fund the project. She applied for and won a $1,000 grant and used the funds to purchase the mannequins for training. To begin the project, the 3West nurse action committee conducted a survey to determine if the patient population believed that learning hands-only CPR would be beneficial. The results showed that 100 percent of the participants believed the project would be beneficial. The nurses proceeded to train 38 additional staff nurses and 15 nursing assistants on how to perform and teach hands-only CPR. The staff used a video demonstration on mannequins, as well as printed materials from the American Hospital Association website. They also kept a record of the patients, families and visitors who were taught and contacted them after approximately one month to determine if they still remembered the key elements and if they found it useful. More than 380 family members, visitors and patients have been taught since November 2014.
Malignant Hyperthermia (MH) is a hypermetabolic crisis that can be triggered by the use of several anesthetic agents, the main pharmacologic trigger being Succinylcholine (a paralytic agent). A hypermetabolic crisis occurring in the operating room is a rare event, but when it does it is a matter of life and death. In order to be prepared to care for the MH patient in a crisis, anesthesia providers and the operating room staff hold a yearly drill to practice the skills needed in a crisis.They discuss the pathophysiology and pharmacology of MH, as well as define each person’s role during the crisis. This year the drill involved four operating room areas: OR East, OR West, SSPROC and BCOR. The Anesthesia High Reliability team (AHRO) wrote a script that taught the signs and symptoms, treatment and medications needed for the MH crisis.The script is used in each practice drill and allows the OR staff to stay current on what to do should the real event happen.
formulation of Dantrolene called Ryanodex.This is a superfast-acting medication kept in the MH carts as the first line drug. The lab work is easy to complete now since the nurses and anesthesia techs configured the lab tubes so that the required tubes are in a “grab and go” bag in the top drawer of the emergency MH cart.There are also laminated task cards that the circulating nurse can use to delegate jobs to staff as they arrive into the OR to help during the code. To provide education in other parts of the hospital where a MH crisis could occur anesthesia assisted with drills in the emergency department, endoscopy unit and cath lab. Additionally a new MH education module was implemented this year in LMS that can be used throughout Rex patient care areas.
Exemplary Professional Practice
Preparing for a Rare but Critical Event
Also this year, Colleen Bradley, BSN, RN, revamped the circulating duties.This streamlined the “to-do” list during a MH code, allowing the nurse to effectively complete a list of items during the code. A multidisciplinary team consisting of nursing, anesthesia, pharmacy and IT created a new MH order set in EPIC@UNC which captures the required lab work and orders the life-saving medication, Dantrolene. The new order set allows a nurse to place one order and it is all covered. The OR, anesthesia and pharmacy worked together and brought in a new
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Exemplary Professional Practice 16
Neonatal Team Integrates S.T.A.B.L.E Concepts into Patient Care A stay in the NICU can be a life-changing experience for families and infants, and the neonatal healthcare team’s impact can be felt not only during that stay but also during transport. Therefore, it is vital that referral centers and community hospitals appropriately stabilize unexpectedly sick and/ “S.T.A.B.L.E. is the most widely distributed or preterm infants for transport while supporting and implemented neonatal education families. program to focus exclusively on the postresuscitation/pre-transport stabilization In June 2013, Rex Healthcare’s Special Care care of sick infants. Based on a mnemonic Nursery partnered with the UNC Newborn to optimize learning, retention and recall Critical Care Center to provide this educational of information, S.T.A.B.L.E. stands for the program to nurses. Rex Healthcare’s Special Care six assessment and care modules in the Nursery committed to providing two classes a year program: Sugar and Safe Care, Temperature, to ensure the neonatology team could give timely Airway, Blood pressure, Lab work, and and appropriate care to infants requiring stabilization. Emotional support (Karlsen, 2013).” Our neonatal healthcare team has successfully integrated key concepts of The S.T.A.B.L.E. Program in the care of our patients, while maintaining our core value of family centered care. This program, in combination with the Women’s & Children’s simulation program, is improving outcomes for infants being transferred to tertiary referral centers and internal unit transfers to a higher level of care. We currently have 65 percent of our special care nurses and 30 percent of our newborn nurses trained. Our team will continue to incorporate The S.T.A.B.L.E. Program into our education curriculum to enhance the level of care we provide to our patients and families.
Preparation of the surgical patient is an art. The Perioperative Planning Center’s (PPC) nurses are experts in documenting the patient’s medical history, performing and reviewing all required diagnostic testing, providing preoperative teaching, and initiating the plan of care to promote safe patient outcomes. Traditionally, PPC served only surgical procedure patients that required an anesthesia consult. In 2013, in anticipation of new heart and vascular procedures and the growing desire for endoscopy and radiology patients to receive anesthesia, the anesthesia department requested that the PPC unit incorporate these procedural patients into the work flow. Faced with this new opportunity to serve other areas, PPC was challenged with inadequate work space, inefficient through-put and limited nursing resources. This led to a team of anesthesia and PPC nurses to visit other facilities in order to determine best practice. After creating a comprehensive business plan in 2014, the PPC unit was renovated to add two patient interview rooms, the lab space was enlarged, and additional nursing resources were hired. The increase in patients for the assigned anesthesiologist to see led to the identification of a new patient appointment type, PAT-RN, which did not require an anesthesiologist assessment. After collaborating with Steven Sherman, MD, of American Anesthesiology of North Carolina, Cindy Wall, BSN, RN, Clinical Manger of Perioperative Care, shared with the PPC team:
on a nursing interview as a screening tool. A patient may now visit the PPC as a “PAT RN” appointment, which includes an extensive interview with a PPC nurse, as well as lab tests and EKGs, but the patient does not see the anesthesiologist until the day of their surgery.” According to Emily Cox, BSN, RN, Team Leader, “PPC saw the number of patients in this category increase significantly over the past year, and these shorter appointment times allowed us to accommodate more than 50 appointments per day. This process required constant communication between the PPC nursing staff and the anesthesiologists to ensure a high quality screening interview, and our staff has done an
Exemplary Professional Practice
Perioperative Planning Center: Excellence Expands to Non-Surgical Procedures
excellent job with this added responsibility.” For the first three months, PAT-RN appointments were limited to the following procedures to test its functionality: gynecology, arteriovenous fistula, bariatric, and thyroid. Upon evaluating the process, the PAT-RN appointment type was viewed as a success. Due to the positive outcomes, anesthesia requested that more procedures be included as a PAT-RN appointment. It became apparent that due to the physical layout and staffing constraints in the pre-operative holding area, only a limited number of patients could be accommodated. The decision to add additional procedures to the PATRN appointments was put on hold until further resources were acquired in 2015. In summary the business plan was implemented successfully and future expansion is expected.
“Our goal is to streamline and expedite the perioperative patient’s experience and to modify practices used by similar institutions, relying
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New Knowledge, Innovations & Improvements 18
Patient-Engaged Evidence-Based Care Planning in the Electronic Medical Record The UNC Health Care System chose to integrate the evidence-based content and tools from Elsevier’s Clinical Practice Model (CPM) within Epic to drive consistent, evidence-based, patient focused interprofessional care during hospitalization in accordance with regulatory agencies. In preparation for the build and implementation, an inter-professional team of experts was formed from across the health care system. This team reviewed the Clinical Practice Guidelines (CPG) provided by CPM and discussed any deviations from current care. These clinicians were empowered to make recommendations that would either drive policy change to keep practice consistent with evidence-based guidelines or suggest not accepting a particular CPG for use within the UNC Health Care System. This is an ongoing process, and Elsevier continually reviews the CPGs for content validity and makes recommendations to organizations that use CPM when a CPG has been updated. Dialogue about practice continues as the same inter-professional team that was created during the build and implementation of Epic@UNC is part of this review process.
New Knowledge, Innovations & Improvements
There have been many benefits to the implementation of CPM at Rex, and the most notable has been that the tool in Epic@UNC triggers a conversation between the patient and nurse at the beginning of the care planning process. This conversation guides individualization of the care plan by defining the patient’s goals, concerns and cultural considerations. The patient and nurse can then mutually agree upon a plan that will meet the patient’s unique care needs. In addition, inter-professional collaboration has improved because the different disciplines document interventions and patient progress toward defined goals within the same framework. Care plan progress notes, which had been a document never reviewed by physicians, are now within Epic@UNC and have become a valuable tool to providers in understanding a patient’s progress at a glance. Nursing care continues to improve because nurses now have evidence-based content at their fingertips with the Clinical Practice Guidelines that are accessible in Epic@UNC. The care plan templates are built on these same guidelines and promote consistency of care and critical thinking on the part of the clinician. By assessing his or her patient and determining the appropriate interventions to implement, a clinician can minimize or prevent potential problems as defined by the evidence. The exciting journey to care planning within the electronic medical record has only begun; care planning will continue to evolve as clinicians learn to fully utilize the tools provided by CPM to enhance patient care and professional practice at Rex Healthcare.
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New Knowledge, Innovations & Improvements
Bar Code Medication Administration (BCMA) Improves Compliance In June 2014, Rex Healthcare transitioned to Epic@UNC for our electronic health record (EHR). At the same time, we had an incredibly successful initiation of Bar Code Medication Administration (BCMA). In order to ensure a successful implementation of BCMA, an inter-professional taskforce was created to develop a structure and process for BCMA. This committee was co-chaired by Julie Broughton, pharmacy financial manager, and April Lalumiere, BSN, RN, clinical nurse manager of labor and delivery. Committee members included clinical nurses and nurse leaders, pharmacists, respiratory therapists, instructional system design staff and an IT director. To ensure a successful implementation of BCMA, the team completed multiple steps. IT studied connectivity on all units, and the need for upgrades was identified and completed prior to go-live. Nursing and pharmacy collaborated to develop an improved process for verification of multi-dose vial medications, specifically correct insulin dosage, eliminating the need for two separate dual verifications. Pharmacy verified barcodes on every medication to ensure scanning success. Nurse education was provided, including hands-on practice with the scanners. The team rounded on all units to ensure everyone was prepared for the upcoming change. Scanning compliance the day of go-live was 78.4 percent for medication bar codes and 88.2 percent for patient arm bands. Within five days, rates increased to 89.4 percent medication compliance and 94.69 percent patient compliance. Within three weeks, scanning reached 93.69 percent medication compliance and 96.52 percent patient compliance. These outstanding rates have been sustained, resulting in fewer medication errors, improved patient safety and increased nurse satisfaction. Since implementation there have been numerous occasions where a nurse was able to identify a potential medication error through use of BCMA. Bar Code Medication Administration is an added layer of verification to ensure the five rights – right patient, medication, time, dose, and route – of medication administration are correct. Nurse satisfaction has been impacted through having reliable technology to improve the ability to efficiently document medications and ensure accuracy of administration.
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New Knowledge, Innovations & Improvements 100%
96.52%
94.69%
95 88.2%
90
93.69% 89.4%
85 80 75 70
78.4%
Patient Arm Band Scanning Compliance Medication Bar Code Compliance
~ ~ Day 1
Day 5
Day 21
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Awards & Honors
Awards and Honors Innovation is not new to Rex Healthcare. Rex has a long history of “firsts” for the Triangle and/ or the state of North Carolina. • The first Magnet hospital in the Triangle. • The first robotic bariatric procedure performed. • The first to complete an endovascular aortic graft. • The first to implement sentinel node procedures for breast cancer. • The first to be named a Bariatric Surgery Center of Excellence. • The first ACoS Comprehensive Cancer Center. • The first to offer tomotherapy - with our partnership with UNC. • Rex Healthcare was named a Silver Best Regional Hospital by U.S. News & World Report for ten specialties in 2014: Cancer, Diabetes & Endocrinology, Gastroenterology and GI Surgery, Geriatrics, Gynecology, Nephrology, Neurology & Neurosurgery, Orthopedics, Pulmonary and Urology. • Recognized as a “Stage 6 hospital” on the Electronic Medical Record Adoption Model by the Healthcare Information and Management Systems Society (HIMSS) along with UNC Hospitals and Chatham Hospital. As of November 2014, only 17 percent of the U.S. hospitals tracked by HIMSS have achieved Stage 6 recognition.
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• Earned the Excellence Recognition from Prevention Partners, validating that Rex has achieved the highest standards in workplace health and prevention by scoring straight A’s in all four WorkHealthy America topics: tobacco cessation, physical activity, nutrition, and culture of wellness. • Honored with the Triangle Business Journal’s 2014 Healthcare Heroes Lifetime Achievement Award for Chairman of the Board, A. Dale Jenkins. Also had four additional Healthcare Heroes Finalists. 2013 Triangle Business Journal’s Healthcare Heroes recognition for Lifetime Achievement was bestowed to Cardiovascular Pioneer Tift Mann, MD. • Honored as one of the country’s “100 Great Hospitals” by Becker’s Hospital Review, the only hospital in Wake County to receive the designation in 2013; also recognized by Becker’s Hospital Review as one of the top “100 Hospitals With Great Orthopedic Programs” for 2013 and 2014; and top “100 Cardiac Hospitals” in 2013. • Named one of the top 50 N.C. FamilyFriendly Companies by Carolina Parent Magazine in 2014, earning that recognition 16 consecutive times. • The National Research Corporation (NRC) named Rex Healthcare a Consumer Choice Award winner every year from 2004 – 2014. • Named one of the Triangle Business Journal’s Healthiest Employer recognitions in 2013.
Congratulations to the following nurses who received specialty certification in their specialty in 2014.
Certified MedicalSurgical Registered Nurses (CMSRN)
Certified Critical Care Registered Nurse (CCRN)
Debra Acord Crystal Ayers Kimberly Baker Brittany Benfield Justin Bonar Dana Bonner Erin Brothers Qingxiao Cheng Susan Crowley Brittany Danielson Jamie Deans Doris Folajin Kimberly Fowler Shana Frazier Dana Garcia Jennifer Harper Nicole Hobgood Lori Hwalek Heather Johnson Maria Jones Margaret Morgan Brittany Moye Aggy Moyer Annamaria Pellegatta Patricia Richardson Noel Rivera April Russell Noralva Torres Kathleen Underwood Neijia Vinton Denise Waulters Elizabeth Wilson Ericka Worthington
Charles Cheek Heather Gwaltney Gregg Johnson Kristen Parham Kelly Sutton Charlotte Van Nortwick Grant Visbeen Cathleen Weathers Brian Wood
Acute Care Knowledge Professional (CCRN-K) Mary Kuzkin
Certified Emergency Nurse (CEN) Jacob Taylor
Certified Wound, Ostomy, Continence Nurse (CWOCN) Rachel Beth Breazeale
Certified Foot Care Nurse (CFCN) Rachel Beth Breazeale Teri Ourada
International Board Certified Lactation Consultant (IBCLC)
Awards & Honors
Certified Nurses in 2014
Joan Smith
Lamaze Certified Childbirth Educator (LCCE) Teresa Martin
Progressive Care Certified Nurse (PCCN) Maria Garcia Helen Horton
Registered Nurse – Board Certified (RN-BC) Caitlin Ortiz
Certified Nurse Operating Room (CNOR) Erin Johnson Jamie Josephson Ruthi O’Berry Doza Primus
2014 Great 100 Nurses Recipient: Donna Balint, RN, Staff Nurse – 7 East
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