news views Summer 2014
A Publication of the Department of Nursing and Patient Care Services University of Maryland Medical Center
Pre-Op Holding Area By Jean Ludwig, MS, RN, CCRN, CPAN
In mid-January of this year, the adult post-anesthesia care unit (PACU) opened a new holding area for pre-operative patients. The purpose was to improve first-case start times and turnover times, and provide a space for placement of regional anesthesia catheters and invasive lines. The pre-op holding area is located in the PACU on the second floor of the Weinberg building. Open Monday through Friday from 6 am to 2 pm, this eight-bay unit often accommodates 12 to 14 patients. Patient flow is managed by the adult PACU charge nurse, and patient transports are handled by the operating room transporters. This nurse-driven unit provides a safe and calm place for patients to wait before going to the surgical suites. Every patient bay in the pre-op holding area has full monitoring capabilities. Upon arrival to the area, patients are warmly greeted by the staff. Patient stress is not uncommon, so everyone works hard to make things easy for the patient and family. Family members are encouraged to stay with the patient until he/she leaves for surgery. Then families are shown to the family waiting area on the third floor, also known as the Healing Garden. Anesthesia providers and operating room nurses have enjoyed the ease of having pre-operative inpatient cases closer to the operating room suites. This allows them to potentially see patients between cases and to request, if needed, any medications, diagnostic tests, or lab work (i.e., chest X-ray, EKG, urine pregnancy test) without delaying the remainder of their care. This unit also supports the University of Maryland Regional Anesthesia Team (UMRAS) in performing regional nerve blocks. The nurses can often be seen putting on surgical bonnets and masks as they assist the UMRAS team with special procedures to ensure pain-free surgery for their patients. During these procedures it is the nurse’s responsibility to ensure overall safety through proper monitoring, completing all paperwork, and correctly administering sedation. Through the collaborative work of the unit nurses, patient care technicians, operating room nurses, anesthesia providers and the UMRSA team, we have been able to identify areas for process improvement projects, policy development and new documentation needs. As we look to the future, we are excited about the important role that the Pre-Op Holding Area is playing in helping to improve the patient experience and the care that is provided them.
Above: Robert Rodriguez, BA, RN, CCRN, assists patient in pre-op holding area. Left to right: Teresita Fernandez, BSN, RN, CPAN; Randy Weigman, PCT; and Jean Ludwig, MS, RN, CCRN, CPAN
Lisa Rowen’s Rounds: A Summer Journey Toward Understanding
Lisa Rowen, DNSc, RN, FAAN, Senior Vice President of Patient Care Services and Chief Nursing Officer
The University of Maryland Medical Center Student Nurse Residency Program is an innovative paid internship that pairs undergraduate student nurses with experienced UMMC nurses for 10 weeks of day-to-day clinical nursing. The residents emerge with realistic expectations of the role of the nurse, enhanced clinical competencies, better communication skills, and the confidence they need to make the most of senior year and seek their first jobs after graduation.
This summer internship for students in BSN programs who are entering senior year has a highly competitive application process. We received approximately 200 applications for 45 positions, and look for the most exceptional candidates. Placed on units across the Medical Center, the student nurse residents work three 12-hour shifts per week, which may include nights and weekends, and have a one-to-one experience with a nurse preceptor continued on page 9.
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In This Issue 1
Pre-Op Holding Area
1
Lisa Rowen’s Rounds
2
Corporate Compliance
3
Steps to Recovery – Post Total Laryngectomy
5
Journal Club
6
Breastfeeding in the NICU
8
Certification Corner
10
Student Nurse Residency Program
12
Improving Medication Safety
14
Respiratory Care for the Smallest Lungs
16
Core Measures
18
Sustaining a Successful Nurse Practitioner Partnership
20 Clinical Practice Update
Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer, and Toya Jackson, Director of Compliance, CHC
In each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) for News & Views. We are looking for new ways to reach out to employees to raise awareness of compliance issues. Please let us know what you think, or suggest topics by emailing compliance@umm.edu or tjackson4@umm.edu. Compliance FAQ Q: Is it correct to submit charges for a clinic visit on the same day that a procedure was performed? A: Yes. If the clinic visit is a significant, separately identifiable service from the procedure or other service, then it may be charged in addition to the procedure.
Documentation for the procedure will be reviewed and if the clinic services are found to relate only to the expected activities of the procedure, the clinic visit charge will be deemed unnecessary which means that an unexpected circumstance or adverse effect would be necessary to justify the clinic visit charge in addition to the procedure provided.
Find news&views online at http://umm.edu/professionals/nursing/newsletter and on the UMMC INSIDER at http://intra.umms.org/ummc/nursing/cppd/excellence/publications/news-and-views
Editor-in-Chief
Kimmith Jones, DNP, RN, CCNS, RN-BC Director of Translation to Nursing Practice Clinical Practice and Professional Development Managing Editor
Susan Carey, MS Lead, Operations Clinical Practice and Professional Development Associate Editor
Mike Costello, MHA Project Specialist Clinical Practice and Professional Development Editorial Board
Lisa Rowen, DNSc, RN, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer Suzanne Leiter Executive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice and Professional Development, Neuroscience, Behavioral Health and Supplemental Staffing Chris Lindsley Director, Communication Services University of Maryland Medical System Anne Haddad Publications Editor University of Maryland Medical System
NEWS & VIEWS is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center. Scope of Publication The scope of NEWS & VIEWS is to provide clinical and
professional nursing and patient care services practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines
Send completed articles via e-mail to mcostello@umm.edu. Please follow the guidelines provided below. 1. Font – Times New Roman – 12 pt. black only. 2. Length – Maximum three double spaced typed pages. 3. Include name, position title, credentials, and practice area for all writers and anyone named in the article. 4. Authors must proofread the article for spelling, grammar, and punctuation before submitting. 5. Provide photos and embedded images in separate .jpg files. 6. Submit trend data in graphic format with labeled axes. 7. References must be numbered consecutively and provided at the end of the article. 8. Editor will seek expert review of articles to verify and validate content. 9. Articles will be accepted based on appropriateness of content and availability of space in each issue. 10. Articles that do not meet the above guidelines will be returned to the author(s) for revision and resubmission.
ISSUE Fall 2014 Winter 2015 Spring 2015 Summer 2015
DUE DATE October 6, 2014 January 5, 2015 April 27, 2015 July 6, 2015
Displaying Credentials
The UMMC Standard for displaying of credentials is based on the ANCC Guidelines. The preferred order is: • highest earned degree (can list more than one if in different fields) • licensure • state designations or requirements • national certifications and honors • other recognitions Nurses with two or more nursing degrees (MSN, BSN) should only list their highest nursing degree, along with other degrees obtained. Example: Betty Smith, MSN, MBA, RN. Why this order: The education degree comes first because it is a “permanent” credential, meaning it cannot be taken away except under extreme circumstances. The next two credentials (licensure and state designations/requirements) are required for you to practice. National certification is sometimes voluntary. Awards, honors, and other recognitions are always voluntary. If you would like additional information, please visit http://www.nursecredentialing.com and search using the word “credentials.”
news &views PATIENT CARE SERVICES | REHABILITATION
Advancing Steps to Recovery Post Total Laryngectomy By Deanna Cohen, MS, CCC-SLP
Receiving a cancer diagnosis can be an overwhelming experience for patients. They may have questions regarding their treatment options, expected outcomes and projected plan of care. Ideally, these questions are answered during a patient’s first few visits, post diagnosis and, throughout their treatment, they are able to continue a dialogue with the medical professionals involved in their care. This process is vastly different for patients with laryngeal cancer undergoing a total laryngectomy. A total laryngectomy is a surgery to remove the larynx (voice box) and separate the trachea from the esophagus. The natural respiratory, communication, swallowing and olfactory systems are permanently altered. Patients are able to discuss their treatment plans pre-operatively — but how will they communicate after surgery? Meeting with a speech-language pathologist for a communication evaluation and counseling is an important part of preoperative care for patients undergoing a total laryngectomy. Intervention by the speech-language pathologist is an important part of the postoperative rehabilitation and recovery stage. The two primary options for communication are speech with a tracheoesophageal voice prosthesis (TEP) and use of an artificial larynx (AL). A TEP is a one-way valve placed surgically in the dividing wall between the esophagus and the newly opened trachea (Figure 1). To speak with a TEP, a patient must block their airway with their thumb. This allows air to flow through the TEP and causes the esophageal tissue to vibrate for speech production. The otolaryngologist determines who is a candidate for TEP placement. While many patients at UMMC are candidates, it cannot be utilized for speech until the surgical sites have healed, which takes four weeks on average. Generally, TEP speech is not initiated until after a patient is discharged from the hospital. Patients will receive speech/voice therapy post-discharge to learn to speak with a TEP. The TEP must be carefully changed every few months (to prevent aspiration) by a licensed speech-language pathologist specializing in head and neck cancer rehabilitation. There are only a handful of speech-language pathologists in the 12-hospital University of Maryland Medical System (UMMS) qualified to manage this patient population, and the University of Maryland Medical Center (UMMC) is currently the only facility offering this service. The other primary option for communication after surgery is use of an artificial larynx (AL). An AL is an external device placed on the neck or cheek that produces sound for speech. For the majority of patients, use of an AL is an easy and effective means to communicate and can be used immediately after surgery. In the
Figure 1. Illustration of how a TEP is used to promote speech
past, UMMC patients were unable to obtain an AL for communication until after discharge. During hospitalization, patients were limited to writing or mouthing words, which can be both frustrating and ineffective. A major anatomical difference after a total laryngectomy is the complete separation of the upper and lower airways. In normal breathing, air is inhaled through the nose and the mouth, is filtered, and when it reaches the lungs, is clean, heated and moist. After a total laryngectomy, the natural filtration and warming systems have been lost, often resulting in increased sputum production and viscous secretions¹. While use of external humidification via a tracheostomy collar mask is used for patients with tracheostomy, it is not considered the most effective practice for patients after a total laryngectomy². In the past, use of a tracheostomy collar for humidification has been our only option at UMMC. After discharge, patients were fitted for devices to restore a more natural respiratory system by the speech-language pathologist. These heat and moisture exchangers (HMEs) are used for both pulmonary hygiene and a means to cover continued on page 4.
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Laryngectomy Recovery, continued from page 3.
Deanna Cohen, MS, CCC-SLP, coaches patient on the use of the artificial larynx.
the stoma for communication with a TEP. With use of HMEs, patients see a dramatic decrease in sputum production in the first few weeks of use. Long-term use of HMEs has been linked to decreased pulmonary illnesses and improved quality of life³. The rehabilitation services (speech-language pathology division) and otolaryngology departments collaborated this past year to further identify the above needs of this specialized patient population and to enhance processes. Diana Johnson, MS, PT, director of rehabilitation services, stated, “Believing in the benefits of applying the device while the patient is in the operating room, our speechlanguage pathologist, Deanna Cohen, MS, CCC-SLP, lobbied hard for a change in practice by meeting with rehabilitation leaders, physicians and the UMMC value analysis committee.” As a result, a new standard post-operative laryngectomy kit — the Provox Laryngectomy Pulmonary Kit — will now be available for all new total laryngectomy patients. “It was really the only option after the clinician (Cohen) noted how this is best applied to meet the patient care needs. Just the right thing to do,” said James McGowan, DHA, vice president of procedural care services. The most significant change is that the kit will be included as part of the surgical procedure, thus eliminating the approximate four-week wait for an effective means of communication. Patients are now better able to communicate wants and needs during hospitalization.
In addition to increasing patient satisfaction, team coordination of care is better facilitated. The kit will include specialized laryngectomy tracheostomal tubes and HMEs. These will be used for airway humidification, airway patency and for easy identification of patients as total neck breathers. Use of HMEs is expected to decrease bedside nursing time by approximately 10 minutes per day and decrease supply costs2. The kit will be for everyday use and will not replace the laryngectomy special airway kit, which is used in the event of an airway emergency. Accessibility to the standard post-operative laryngectomy kit is expected to improve post-operative care and immediately start patients on the correct path for healing. References 1. Zuur JK, Muller SH, de Jongh FHC, van Zandwijk N, Hilgers FJM. The physiological rationale of heat and moisture exchangers in post-laryngectomy pulmonary rehabilitation: a review. Eur Arch Otorhinolaryngology. 2006;263:1-8. 2. Merol JC, Charpiot A, Langagne T, Hemar P, Ackerstaff AH, Hilgers FJM. Randomized control trial on postoperative humidification after total laryngectomy: External humidifier versus heat and moisture exchanger. The Laryngoscope. 2011;122:275-281. 3. Brook I, Bogaardt H, van As-Brooks C. Long-term use of heat and moisture exchangers among laryngectomees: Medical, social, and psychological patterns. Annals of Otology, Rhinology, and Laryngology. 2013;122(6):358-363.
Would you like to have your article published in News&Views ? Submitted articles should: • Present clinical and professional nursing practice topics in inpatient, procedural and ambulatory areas that are evidence-based, innovative, and outcomes driven. • Focus on divisional, departmental and/or organizational strategic goals. See page 2 for submission guidelines.
news &views Journal Club
Effect of not monitoring gastric residual volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: A randomized controlled trial By Catherine Wolkow, PhD, RN
Catherine Wolkow, PhD, RN, from the medical intermediate care unit (MIMC) on North 10W, hosted the June Journal Club to review the article, “Effect of not monitoring gastric residual volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: A randomized controlled trial” (Reignier et al., 2013). Ventilator-associated pneumonia (VAP) is a hospital-acquired infection (HAI) that prolongs hospitalization (Reignier et al., 2013). According to the Centers for Disease Control and Prevention (CDC), VAP accounts for 15 percent of all HAIs and is associated with 20 – 41 percent mortality (Reignier et al., 2013).
At UMMC, VAP rates are measured in the surgical intensive care unit and the cardiac care unit. In both units, the rates for 2014 are below the targets set by the National Healthcare Safety Network (UMMC Infection Control Division). Although VAP rates are acceptable at UMMC, understanding the risks for VAP are important for preventing these serious infections. The purpose of this randomized controlled trial by Reignier et al. (2013), was to examine whether the practice of monitoring gastric residuals is effective in preventing the development of ventilatorassociated pneumonia in patients receiving tube feedings. Aspiration of gastric contents may increase the risk of developing VAP. As such, it has been widely held that routine monitoring of enteral feedings residuals, which may result in discarding large amounts of residuals, reducing the rate, or stopping enteral feedings, may reduce the risk of gastric aspiration and thus, the incidence of VAP in ventilated patients.
In this study, VAP rates in ventilated patients whose gastric residuals were not routinely monitored were compared to those who had routine monitoring. Over nine months, 1,984 adult patients from the medical and medical/surgical intensive care units (ICUs) in nine French hospitals were assessed for eligibility. To be included in the study, participants had to be intubated for at least 48 hours and had to have received enteral nutrition within 36 hours of intubation. Five hundred and fortytwo patients were eligible and randomly assigned to either the intervention (no monitoring) or control (routine monitoring) groups. The study was designed as a 10 percent non-inferiority study, which allowed for the study group to be slightly (10 percent) less effective than the control group. Findings showed no significant difference between the study and control groups in VAP rates, other ICU-acquired infections, mechanical ventilation duration, ICU length of stay, or mortality. In particular, VAP occurred in 38 of 227 (16.7percent) participants in the intervention group (no monitoring) and 35 of 222 (15.8 percent) participants in the control group (routine monitoring). Compared to controls, the intervention group experienced more episodes of vomiting, but were more likely to have attained their nutritional caloric goals. This study demonstrated that routine gastric residual monitoring did not reduce VAP occurrence or adversely affect other patient outcomes; however, routine residual monitoring resulted in fewer patients attaining their calorie targets. The authors concluded that, similar to other research, little evidence supports the role of gastric content aspiration as a major cause of VAP. Rather, subglottic secretions, which are more likely to contain the microorganisms responsible
for VAP, gain access to the lungs when they leak around the endotracheal tube cuff. The authors cited other studies which demonstrated oral antiseptic use was effective in reducing VAP occurrence. This study encourages focus on proven mechanisms of reducing VAP risk, specifically the microorganisms found in subglottic secretions. Best practices and education should ensure that patients receive appropriate oral care as the best VAP prevention strategy. Better measures for enteral feeding intolerance are encouraged to ensure that patients attain their calorie targets without vomiting. A limitation of this study was that doctors and nurses could not be blinded to whether residuals were checked or not. This could have biased staff to be more observant about feeding intolerance in the intervention group. However, the authors note that study group patients were more likely to attain their calorie targets, arguing against this possibility. Discussion
Nurses, nursing students, and dietitians participated in reviewing the article and its implications. Dietary staff was particularly insightful about the varying tube feeding preferences among different UMMC units and the factors affecting a patient’s tolerance of enteral feeding. Some concern was expressed that post-pyloric feeding tubes were preferred on some units as prevention against VAP, even though these tubes are more difficult to insert, which can delay initiation of enteral feeding. The group also discussed the importance of analyzing results from the participants who completed the study (per-protocol population), as well as the entire group of enrolled participants (intention-to-treat population). Reference Reignier J, Emmanuelle M, LeGouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding. Journal of the American Medical Association. 2013;309(3):249-256.
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PATIENT CARE SERVICES | CLINICAL NUTRITION
Breastfeeding in the Neonatal Intensive Care Unit (nicu): Sometimes it Takes a Village… Laura K. Wohlberg, MS, RD, LDN, senior neonatal nutrition specialist
Mike and Sara Kerr were a young couple awaiting the arrival of their first child. They wanted the very best for their daughter, and both being health-conscious advocates, it was an easy decision to choose to breastfeed. However, their baby was in the NICU. Why was breastfeeding important to the Kerrs, even when faced with so many other pressing concerns? The American Academy of Pediatrics (AAP) 2012 Policy Statement: Breastfeeding and the Use of Human Milk, states, “the potent benefits of human milk are such that all preterm infants should receive human milk.” 1 Key benefits include lower rates of necrotizing enterocolitis (NEC) and sepsis2, contributing to lower long-term growth failure and neurodevelopmental disabilities3-4, lower rates of retinopathy of prematurity5, as well as fewer hospitalization readmissions one year post-NICU discharge6. Believing in these benefits, could the Kerrs’ goal of breastfeeding their daughter be achieved? Her clinical status made it a difficult challenge.
Mike, Sara and Emma Kerr
At 32 weeks of gestation, their daughter was found to have bilateral pleural effusions requiring fetal intervention to drain the fluid in the chest. At 35 weeks of gestation, Emma came into this world by C-section for non-reassuring fetal heart tones. At delivery, Emma was intubated and, within the first few days of her life, a chest tube was inserted to drain accumulated fluid. The fluid was determined to be chylous, indicating a chylothorax. A chylothorax is the accumulation of lymphatic fluid in the pleural cavity. When a baby has a chylothorax, he/she often requires parenteral nutrition or is given a special formula (Enfaport), that is high in medium-chain triglycerides and contains a limited amount of long-chain fatty acids. Long-chain fatty acids are absorbed through the lymphatic system and may contribute to increased pleural output. Human milk is not frequently used with infants with chylothorax because of its high long-chain fatty acid content. For Emma, even with the special formula, her chest tube drainage increased and she could no longer receive enteral feedings. For the next several weeks Emma received only total parenteral nutrition (TPN) and her chest tube drainage improved. Despite these setbacks, Mike and Sara never wavered in their desire or intent to give breast milk to their daughter. In conjunction with the University of Maryland Medical Center’s (UMMC) commitment to increase and support breastfeeding, Cheryl Holden, BSN, RN, IBCLC, RLC, met regularly with the parents from day one. Cheryl encouraged Sara to continue breast pumping and subsequently shared articles and information regarding the use of breast milk for babies with a chylothroax. Mike and Sara did their own research, continuing to advocate for using breast milk with the team. Natalie Davis, MD, assistant professor of pediatrics and the individual supervising Emma’s care, had experience using ‘skimmed’ breast milk for babies with chylothorax and supported the parents’ goal, which provided them with much-needed hope. One month after birth, Emma was extubated and restarted on the special formula, Enfaport. At this point, Elias Abebe, MD, assistant professor of pediatrics, and the neonatologist in charge of Emma’s care, approached me to see if I could figure out how we could implement the use of “skimmed’ breast milk for Emma. The quest for skimming Emma’s milk began. Our first step was to see if we could implement the process used in the PICU, allowing the milk to settle (fat rising to the top) and suction off the lower liquid portion. Afterwards, a ‘creamocrit’ was completed, which is a procedure that spins the breast milk in a centrifuge to analyze the percent of fat. This revealed the remaining breast milk was still too continued on page 7.
news &views Breastfeeding in the nicu,
continued from page 6.
Left to right: Cheryl Holden, RN, IBCLC, RLC; Joan Treacy, MS, RN, RNC; Shirley Coles, CLA II; Diana MacFarlane, BS, MLS III HEW; Shanti Lewis, RD, CNSC, CSP; Johnnie Chan; Laura K. Wohlberg, MS, RD; Elias Abebe, MD; and Natalie Davis, MD
high in fat to be used. The team felt the breast milk would need to be centrifuged further to remove as much fat as possible. Luckily, Jane Munoz, RN, IBCLC, RLC, a NICU nurse and lactation consultant, had recently attended a conference where Diane L. Spatz, PhD, RNBC, FAAN, professor of perinatal nursing and the Helen M. Shearer Professor of Nutrition at the Children’s Hospital of Pennsylvania (CHOP), shared her research on the routine practice of spinning mothers’ milk for infants with chylothorax at CHOP. I emailed Spatz, who graciously shared her research and the procedures CHOP follows in centrifuging mothers’ milk. Equipped with the guidelines on how to do it, the issue became finding a centrifuge. My quest took me to the Laboratories of Pathology on the second floor of the North Hospital, where I began asking questions. I was assisted by Shirley Coles, CLA II, who was helpful in explaining the different centrifuges, checking with her supervisor, and then directing me to Alan Burris, associate administrator, laboratories of pathology, whose permission I would need. Burris promptly returned my phone call, explaining it would not be possible to use the lab equipment. He directed me, instead, to a technician in the department of biomedical engineering who helped us find a centrifuge that could be sterilized and made operable within a few days. With approval from Johnnie Chan, biomedical technical team leader, we received permission for the parents to use the centrifuge machine. I now realized that we would need 15 ml conical tubes to spin the breast milk. Diana MacFarlane, BS, MLS III HEW, liaison for the laboratory integration team and a frequent visitor to the NICU for lab inquiries, came to our assistance. She researched the tubes and provided all the necessary information regarding where to purchase them and the cost. In addition, she was able to supply some tubes so the parents could get started. After she had been informed of this entire undertaking, the NICU nurse manager, Joan Treacy, MS, RN, RNC, agreed to purchase the tubes for the family. Finally everything was coming together. The parents, equipped with the centrifuge, tubes, and guidelines from CHOP, embarked on the labor-intensive process of spinning the breast milk. The Kerrs converted their home kitchen into a lab, calling upon parents and friends to help with the assembly line process of centrifuging, skimming, and making bottles of skim milk for Emma. Shanti Lewis, RD, CNSC, CSP, my co-worker and dietitian for the team managing Emma, accepted the challenge of designing the plan
to transition from the Enfaport to all skimmed breast milk. Emma was started on skimmed breast milk on day 49 of her life and successfully transitioned to full skimmed breast milk on day 55. To meet her nutritional needs, Emma’s skimmed breast milk was concentrated with Monogen, a powder formula high in medium-chain fats. On day 61, Emma was transferred to a facility closer to her home, needing only one additional week before she was able to safely transition to full-fat breast milk. Mike and Sara took Emma home on October 25. Since then, Emma has done extremely well and has had no breathing or feeding issues. She turned one year old on August 9. Emma’s success story is one of many we see here at UMMC. Her positive outcome is certainly due to the skill and expertise of the medical and health care team that cared for her during her NICU admission. Her story highlights the best of UMMC, when “the village” comes together to care for our patients.
A special thanks to Natalie Davis, MD; Shanti Lewis, RD, CNSC, CSP; and Ellen Loreck, MS, RD, for their contributions to this article.
References 1. Eidelman I, Schlander R. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012; 129 (3): 827-841. 2. Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr 2010;156(4):562–567. 3. Hintz SR, Kendrick DE, Stoll BJ, et al; NICHD Neonatal Research Network. Neurodevelopmental and growth outcomes of extremely low birth weight infants after necrotizing enterocolitis. Pediatrics. 2005;115(3):696–703. 4. Shah DK, Doyle LW, Anderson PJ, et al. Adverse neurodevelopment in preterm infants with postnatal sepsis or necrotizing enterocolitis is mediated by white matter abnormalities on magnetic resonance imaging at term. J Pediatr. 2008;153(2):170–175. 5. Okamoto T, Shirai M, Kokubo M, et al. Human milk reduces the risk of retinal detachment in extremely low-birthweight infants. Pediatr Int. 2007;49(6):894–897. 6. Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O’Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol. 2007;27(7): 428–433.
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Certification Corner
Creating a Unit Culture that Embraces Certification Laura Bothe, BSN, BA, RN, PCCN, SCN I Jessica Farace, BSN, RN, PCCN, SCN I Katherine McGinley, BSN, RN, PCCN, SCN I Buffie Wingo, BSN, RN, PCCN, SCN II Karen A. McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN
Achieving specialty certification can bring a great deal of personal pride to a nurse; however, when an entire unit fosters and celebrates certification of all eligible nurses, that pride extends to the entire staff. In an effort to develop a staff that appreciates, fosters and celebrates certification, there is no doubt that the encouragement of a manager, clinical nurse specialist, or educator certainly helps, but peer support and expectation are perhaps the most powerful in creating a unit culture that embraces certification. On Multitrauma Intermediate Care 6, Buffie Wingo, BSN, RN, PCCN, SCN II, describes how she became the first nurse on her unit to achieve certification, thereby blazing a trail that many have followed.
“Certification demonstrates a nurse’s professional commitment to his/ her practice and provides recognition of expertise within a specialty area. I believe it validates a nurse’s commitment and desire to provide high-quality care with the most up-to-date knowledge and skills. In my desire to advance in the Professional Advancement Model here at UMMC, I became interested in pursuing my certification in progressive care nursing (PCCN). I became the first intermediate care nurse on our unit and in trauma to become certified. I achieved PCCN certification in October 2011, and since then have successfully mentored several nurses in their efforts to become certified. We currently have 12 certified nurses on our unit.”
The majority of eligible staff to sit for the American Association of Critical Care Nurses’ progressive care certified nurse exam have met the challenge and have become certified in large part due to Wingo’s encouragement and mentoring.
Other leaders on the unit have gone on to mentor staff. For example, Jessica Farace, BSN, RN, PCCN, SCN I, who received her PCCN in January of 2014, explains:
“We have a core group of senior clinical nurses (SCNs) on our unit who are all progressive care certified nurses; each is responsible for mentoring a group of staff. Each SCN encourages their mentees to grow and develop to be the best possible professional nurse they can be. Serving as a charge nurse and resource for the unit, I felt it was necessary for me to continue my education in order to better serve my patients and fellow coworkers. I felt the best way to grow as a role model was to gain more knowledge and insight about the population we serve and I felt I could accomplish this by becoming certified. Receiving my certification was an honor. I felt as though I had reached a new level of knowledge and pride based on my achievement. I was able to lead my unit as charge nurse with more confidence as a resource for fellow coworkers. The continuing education unit (CEU) requirements needed to keep my certification current encourages me to stay up to date with current changes in health care. As a certified SCN, I am now able to encourage the members of my mentor group to seek out educational opportunities and certification.”
Likewise, Laura Bothe, BSN, BA, RN, PCCN, SCN I, describes her motivation to achieve and maintain her certification.
“Desire to continue my education and professional growth were the driving forces behind my decision to achieve my professional nursing certification. Obtaining my certification allowed me to expand my nursing knowledge and advance my clinical practice skills set. I believe that by obtaining
my PCCN, I am better prepared to meet our high standards of practice by providing safe and skilled care to my patients and their families.”
Katherine McGinley, BSN, RN, PCCN, SCN I, describes how she developed her desire to seek certification.
“In nursing school, all of my professors had many letters after their names, which I later learned signified that each had pursued their own professional development by becoming certified in their specialty. As I grew in my nursing role on the multitrauma intermediate care unit, more and more senior nurses were becoming PCCN certified, and it peaked my interest. Since I wanted to continue my career on the unit and desired to develop myself professionally, I decided to pursue my PCCN certification. I purchased the recommended text, signed up for the AACN on-line course, and scheduled myself to take the exam in January 2014, when I successfully became a progressive care certified nurse. Having a certification doesn’t just mean having all those letters after your name; it means you have dedicated yourself to becoming the best nurse in your specialty. It signifies that you want to challenge yourself to be a strong resource for your unit and a role model to other staff.”
It only takes one nurse, like Wingo, to step forward, achieve certification and encourage others to do the same so that an entire unit embraces certification. Every UMMC nurse has that potential to drive change by developing himself/herself and then inspiring and mentoring others. Step forward and be that nurse!
news &views Rounding Report,
continued from page 1.
with whom they share a patient assignment. Within the residency, there are mandatory education days and the residents are expected to present a project and keep a journal. For their final journal entry of the summer, the residents were asked to provide their perceptions and comments about the program. Read the insightful excerpt, below, written by Jessica Wagner, who worked on Labor & Delivery. I was particularly moved by Jessica’s journal excerpt (see below), as it poignantly expresses the uncertainty and anxiety of the novice. Her awe of the profession and its quiet mysteries is apparent, and reminds us not to take anything we do for granted, because everything we do can be meaningful to someone else. The dichotomies Jessica refers to are ever-present in nursing and health care, where the joy of helping a patient to heal holds hands with the heartbreak of seeing the next patient falter. This cycle is both routine and shocking, and the nurse’s proximity to it is a privilege.
pilation of This summer has been a com opposites. ing crib adjectives and scenarios des Tale of A “ in t Charles Dickens wrote it bes es, it tim best of Two Cities” : ‘It was the was the age of was the worst of times, it foolishness, it wisdom, it was the age of was the epoch of it was the epoch of belief, son of Light, it was incredulity, it was the sea was the spring of the season of Darkness, it despair…’ I have hope, it was the winter of ure of myself than never felt more surely uns Surely I have I have these past 10 weeks. table, independent what it takes to be a respec nurse, right? be certain, Theoretically you want to g, but my experience confident, sure of everythin is when I am has not supported this. It to accomplish age sure of myself that I man sterile field the g something oafish like breakin uncertainty is er, it in an operating room. Howev and curious. that has made me cautious d enough to ask Curiosity has made me bol cautiousness has questions of everyone and
Excerpt from student nurse resident, Jessica Wagner’s journal
The 2014 Student Nurse Residency Program ended as others have in past years, with a meaningful “graduation” ceremony. Eyes shining, the residents, accompanied by proud parents, significant others, children and friends, listened to the speakers commend their performance and speak about their futures in nursing. As they advance to their final year of school, they will hold this summer experience close to their hearts and use it as a filter for future challenges, adding perspective and insight to their upcoming clinical experiences.
sterile field more kept me from breaking the than once. residency This dichotomous summer did not I hing has provided me with everyt . If I were able know to hope to experience es on my wish to check off all of the box ough everything list, I would have run thr This says ks. within the first two wee gination and of something both of my ima tanding of the the divide between my unders actuality of it. registered nurse role and the n laymen persons This profession is more tha my privilege to can imagine and it has been s summer. show that to patients thi say that I am proud of my ability to ghed, cried and I have smiled, frowned, lau to remind myself bit my cheek until it bled t in my life. This that I am not always firs and I will program is truly a blessing, se who inspired forever be grateful to tho to achieve it and me to pursue it, helped me walked me through it.
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Summer 2014
Another Successful Student Nurse Residency Program Cyndy Ronald, BA
The University of Maryland Medical Center’s (UMMC) student nurse residency program has just completed its eighth year. This highly competitive program has been a valuable recruitment tool for top new graduate nurses at the Medical Center. Over 81 percent of last year’s residents have been hired as new graduate nurses, many of whom are starting this summer. The summer internship places students entering their senior year of nursing school on units ranging from acute medical/surgical to critical care in a variety of specialties. While here, they worked one-on-one with a nurse preceptor (three 12 hour shifts/week), attended bi-weekly education sessions, completed journals and developed an evidence-based poster which they presented in the Weinberg Atrium on July 24 and 25.
2014 UMMC Student Nurse Residents
The program received more than 160 applications from all over the country and selected 49 students from 14 different schools of nursing. The students started on May 19 and many shared the same emotions of excitement, anxiety, apprehension and insecurity. Through their sessions with mentors from Clinical Practice and Professional Development, reports from preceptors, and journal entries, we are happy to report that each of the residents learned a great deal during the 10 weeks. They have grown in their skills and confidence toward becoming competent, safe and compassionate nurses. The students could not say enough good things about their time at UMMC. The units, preceptors, senior leadership and others with whom the students interacted, embraced them, supported them and offered multiple opportunities for learning. Because of this incredible experience, the students feel they are well on their way to transitioning from student to new graduate nurse and will emulate the positive professional behaviors they witnessed. We are extremely proud of this group of student nurse residents and would like to share some of their last journal entries submitted to us as they reflect on the UMMC culture. continued on page 11.
news &views Successful Student Nurse Residency Program, continued from page 10.
Martina Cade, Surgical ICU Resident My preceptor suggested that I keep a list of all of the clinical skills that I have done this summer, and that list is more than four times longer than my original list. Looking back, I can’t believe all that I was able to accomplish in such a short time. Seeing all that I have done makes me excited for all that I will do in the future. Helen Haines, Bone Marrow Transplant Resident Each of my patients has taught me something about myself and about how I can better myself as a future nurse. I have been challenged in countless ways by patients to continue to push myself to learn as much as possible, so that I can live out my career as a nurse to the fullest potential. Lucy Davidoff, NICU Resident From the fastest minutes to the slowest ones, the happiest days to the saddest ones, every minute I have spent on the NICU was fulfilling and worthwhile.
Natalie Colville, student nurse resident, pediatric intensive care unit
Bradley Dodson, Medicine Telemetry 13 E/W Resident I feel a deep sense of pride and honor to be working in this field and I realized in this moment just how important every detail can be when you are in charge of someone’s life and well-being. Mickaela Berry, Cardiac Surgery Step-down Resident I feel like I have not only grown as a nurse, but as a person. I keep saying this in all my journals, but I can see my future clearly ahead of me now because of this experience. Most students starting off their senior year in college have no idea where life will take them immediately after graduation, but I do. I am so grateful to have found a profession that is as rewarding and challenging as nursing.
Martina Cade, student nurse resident, surgical intensive care unit
Daniel Miyamoto, Medical ICU Resident In summary, the residency has been a great experience. I have learned more than I can really quantify. I have seen and done things that will make me a better nurse. My relationship with my preceptor has been great, and I could not have asked for a better one. The other nurses, patient care techs, respiratory therapists, physicians, secretaries, and the entire staff have been great and I will honestly miss being on the unit. I really couldn’t have asked for this experience to be better.
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Summer 2014
SPOTLIGHT ON PHARMACY
Improving Medication Safety with Complete Orders and Continuous Infusion Protocols By Quyen Nguyen, P4 pharmacy student, Notre Dame of Maryland University, School of Pharmacy
One of our responsibilities as health care professionals is to provide the best possible care for our patients. Medication errors can occur at any point in the medication-use process, which includes prescribing, dispensing, administering and monitoring. To reduce medication errors, we need to be cognizant of required components of medication orders and appropriate protocols for continuous infusions. Research shows that approximately 75 percent of medication errors occur during the prescribing and administration processes.1 The implementation of computerized physician order entry (CPOE) was initially thought to reduce the amount of prescribing errors. However, further studies on CPOE showed that the process actually contributed to some medication errors.2 During the medication-ordering process, prescribers may still leave out pertinent information that could potentially lead to an error later in the medication-use process. Therefore, it is important to become familiar with the medication order components to ensure that it is complete and to catch errors that others may have missed before the error reaches a patient. If any of the order’s parameters are missing, or if there is a discrepancy, the prescriber and/or pharmacist should be contacted before the medication is administered to the patient. Table 1: Components of a Complete Medication Order3,4 Patient name Date and time order was written Drug name (generic and/or trade, if applicable) Drug strength Dosage form Drug dose Route and site of administration Frequency and duration of therapy Indication of therapy Special instructions (e.g., withholding or adjusting doses based on patient response and laboratory results) • Prescriber signature or name and/or contact information (if order was via telephone, verbal, or written) • Signature of licensed practitioner taking down order (for telephone, verbal, or written orders) • • • • • • • • • •
In addition, prescribers often write duplicate PRN (“as needed”) orders for patients. These can be medications from the same class of drugs or medications that are administered by different routes. PowerChart® will now have a “PRN reason list” for opioid and nonopioid (acetaminophen, nonsteroidal anti-inflammatory drugs) medication orders. Prescribers will be required to give a specific reason when they order such medications. This new update will help reduce the number of duplicate orders and clarify the indications for the ordered medications, thus preventing administration errors. The new “PRN reason list” will consist of options such as pain (with a severity scale), headache, fever, withdrawal symptoms, or dyspnea. Pain and dyspnea will be further categorized into mild, moderate, or severe pain based on the patient’s reported pain score. If the indication is not stated in the order, the provider will have to be contacted to change/modify the order.
Additionally, when the same medication with multiple routes of administration is ordered, the conditions for the preferred route should be specified to help reduce confusion among nurses during the administration process. For example, if a patient is ordered an anti-emetic agent both by mouth (PO) and intravenously (IV), the order should specify when the medication should be given by which route (e.g., give IV if patient is NPO (nothing by mouth). Infusion titration protocols are another important resource for nurses to help guide them in titrating continuous infusions for patients and preventing errors in administration. The protocol is available on the University of Maryland Medical Center (UMMC) intranet page and is attachment C, Infusion Titration Protocols, of policy MM-003, Titration Dose Range Orders. Unless otherwise specified by the provider, the titration protocol for the ordered medication infusion should be used. If the infusion titration endpoint cannot be reached by following the instructions in the protocol, the prescriber should be contacted for a new order. If this is the case, the prescriber must include the following requirements when writing a new order: ◗◗ Initial infusion rate (and, if applicable, bolus dose), ◗◗ Titration dose, ◗◗ Frequency of titration, ◗◗ Maximum infusion rate, ◗◗ Titration endpoint(s), and ◗◗ Specific parameters (rate, dose, frequency) for weaning. Medication errors are almost always preventable. Being aware of important components of a medication order and referring to the infusion titration protocols during administration can help prevent mistakes from reaching a patient and causing unnecessary harm. All medication orders should be verified by the nurse prior to administration to the patient. If there are any discrepancies or errors, the medication should not be administered to the patient and the pharmacy should be contacted to determine the appropriate actions. It is important to always keep in mind the five rights of medication administration (the right patient, drug, dose, route and time) as these can have a significant impact on reducing administration errors and preventing patient harm. References 1. Committee on Patient Safety and Quality Improvement. Improving Medication Safety. Washington, DC: The American College of Obstetricians and Gynecologists, 2012. ACOG publication no. 531. 2. Koppel R, Metlay JP, Cohen A et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-1203. 3. American Society of Hospital Pharmacists. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993; 50:305-14. 4. ISMP’s Guidelines for Standard Order Sets. Horsham, PA: Institute for Safe Medication Practices, 2010.
news &views
Pediatric
Nurs覺ng EDUCATION SYMPOSIUM
NOVEMBER 6, 2014
Fall into Enlightenment Location: Southern Management Corporation Campus Center 621 West Lombard Street For further information contact: Whitney Sibol Special Projects Coordinator, R Adams Cowley Shock Trauma Center Email: wsibol@umm.edu Phone: 410-328-2035 Karen A. McQuillan, RN, MS, CNS-BC, CCRN, CNRN, FAAN Clinical Nurse Specialist R Adams Cowley Shock Trauma Center Email: kmcquillan@umm.edu
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PATIENT CARE SERVICES | RESPIRATORY
The Smallest Lungs Need Our Help— Respiratory Care to the Rescue Christopher D. Kircher, MS, RRT-ACCS and Paul Johnson, RRT
Respiratory therapists at the University of Maryland Medical Center (UMMC) have a unique opportunity to experience and acquire the special skills necessary to work with all patient populations. Supporting this model has been the primary focus of the department’s operational plan, including education, focused leadership and medical direction. The respiratory care department is staffed with well-trained neonatal and pediatric therapists who provide support from the emergency room, through the acute care unit and on to the intensive care unit. Much of the same equipment and therapy is provided throughout the facility; however, the application in the pediatric and neonatal populations requires a special expertise. Many of our current respiratory care program affiliations benefit from this exposure, which is often why many of the newly hired therapists choose to start their career at UMMC. “I have had the pleasure of being the pediatric and neonatal respiratory medical director for many years here at UMMC,” said Kyle Walker, MD. “The pediatric respiratory therapists are a critical component to providing intensive care to both pediatric and neonatal patients as the majority of admissions are related to respiratory issues. They contribute to the care of these patients not only by providing a dizzying array of support devices in all shapes and sizes (just like the patients), but they also participate in medical rounds with clinical insight and suggestions as we create a multidisciplinary plan of care. This is a skilled and diverse group of highly trained individuals who are fierce patient advocates and a delight to work with.” Respiratory therapists don’t often have the opportunity for this broad-spectrum exposure, and it is this exposure that makes UMMC a major destination site for our profession. When a respiratory therapist joins the department, the orientation and education process initially focuses on a critically robust adult intensive care experience. By design, this facilitates better preparation for their credentialing exams and provides the level of proficiency necessary to adequately staff our large array of adult intensive care units. Traditionally, our requirement has been for therapists to work nine months to a year before entering a pediatric and neonatal orientation — a process many of our therapists have benefitted from over the past few years. In more recent years, experienced pediatric and neonatal therapists have joined UMMC and have more quickly completed this training. In fiscal year 2015, staff will expand to nearly 28 therapists per shift, resulting in the need for improved tracking of where staff work and to ensure required training and competency are provided. Officially entitled the “Where You Work Initiative,” a regularly updated document tracks where each therapist works and is made available in the staff office. The tracking document aids managers
and staff in deciding how best to create shift assignments so that levels of expertise can be placed where they are needed. The required movement of staff throughout their oriented areas, though challenging and stressful at times, keeps UMMC respiratory care standards high and assures that newly hired therapists will be afforded the same work opportunities throughout the facility. “The American Association for Respiratory Care’s 2015 and Beyond goals set forth very high standards for the future of respiratory therapists working in the United States,” said Matt Davis, RRT, education coordinator for respiratory care. “The scope of practice is ever expanding and requires higher levels of training for all respiratory therapists. At UMMC, we have already shifted to a cross-trained model and are on the leading edge of professional practice.” The continued advancements in the way we care for neonatal and pediatric patients has required an ever-increasing level of support from the respiratory care department. In the past several years, focused training has been provided in the support of medical devices such as the CareFusion 3100A Oscillator, Bunnel Jet ventilator, and high-flow therapy. Additionally, medications have expanded to include several pulmonary vasodilators, as well as a best-practice modality to better manage apnea testing. As we prepare for the 2015 relocation to the new neonatal intensive care unit (NICU), the respiratory care department will expand its role in support of lab testing with the use of the i-STAT point-of-care system. This will bolster the respiratory therapist’s scope of practice by including laboratory draws from heel sticks and indwelling catheters, a source of professional advancement and practice shared by peers, both regionally and nationally. Developments such as this provide innovative opportunities to partner with our nursing colleagues and ultimately make the clinician’s work at the bedside more timely and efficient. Mary Jo Simke, MS, RN, nurse manager, pediatric intensive care unit (PICU), was pleased to say that, “the contributions and value of respiratory therapists actively involved as key members of the pediatric patient/family health care team cannot be overstated. Having knowledgeable, pediatrictrained therapists and open, respectful communication are essential to the care of our patients! An example of prior partnerships of nurses and physicians with therapists was the development of weaning protocols, patient education content/materials, and the collection of QI data for pediatric asthma patients. Recent collaborative examples include developing a reference manual for tracheotomy patients and instituting weaning protocols for high-flow oxygen therapy.” There are times when clinicians recognize gaps in the care respiratory therapists provide and actively take steps to make improvements. It has always been important for family members to be educated and prepared to take care of their children as they transition from a medical facility to home. Last year, design of a tracheostomy education and care handbook was one such example. Jenna Collins, BS, RRT-NPS, and Francine Jones, BS, RRT, both neonatal respiratory continued on page 15.
news &views Respiratory Care,
continued from page 14.
University of Maryland Medical Center, in collaboration with Johns Hopkins Hospital, presents:
m a r y l a n d
Comprehensive
Stroke Conference 2014
Save the date: Friday, november 7, 2014
Left to right: Paul Johnson, RRT; Francine Jones, RRT-NPS; Annie Grace, BSN, RN; and Jenna Collins, BS, RRT-NPS
therapists, worked to develop several initial drafts. Now having partnered with Annie Grace, BSN, RN, a nurse with the ear, nose and throat specialty, Dina Metwally, MD, medical director for the NICU, and a parent of a trached child who also serves on the NICU advisory committee, this handbook now has its own committee structure and will soon become part of everyday practice. Says Paul Johnson, RRT, pediatric supervisor for respiratory care, “The truly amazing thing about working with these kids is that clinicians develop such meaningful relationships with their families as well. Excellence in customer service is essential as we work to provide even the smallest of comforts. As a supervisor for the pediatric and neonatal areas, I have been given an opportunity to help support a wonderful group of therapists, nurses, and physicians!” As we progress through 2014 and beyond, we will continue to look for and provide opportunities to improve the patient’s care and experience. Whether it is the development of patient and family education materials, improved policy and care modalities, or the continued focus on pediatrics and neonates during our annual professional conferences, dedicated respiratory therapists are making a difference … and it all starts at the beginning!
th
annual
N u rs e Pract i t i oN er & Ph ys i ci a N assista N t
Cli n i Ca l Con fer enC e Taking Your Practice from Good to Great! Keynote SpeaKer: Amy Herman, JD, MA – The Art of Perception®
Sav e
Advanced Practice Nursing
the
date
nove mbe r 19, 2 014
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Core Measures
Flu Season: It’s Just Around the Corner Patty Dumler, BSN, RN, quality measures coordinator
Influenza (flu) and pneumococcal vaccines are not only core measures we monitor and report to the Joint Commission, the Centers for Medicare and Medicaid Services (CMS), the Maryland Health Care Commission, and the Health Services Cost Review Commission (HRCSC) for Quality-Based Reimbursement, they are important vaccines that can protect our patients from serious illness and death. Below are excerpts from the specifications manual for national hospital inpatient quality measures (the core measures manual), which illustrates why influenza and pneumococcal vaccinations are best practice. “Pneumococcal infection causes an estimated 5,000 deaths from invasive disease annually in the United States. All pneumococcal infections, including invasive and noninvasive disease, result in approximately 2.4 million days of hospitalization. A sizable proportion of these cases and deaths are potentially preventable through vaccination. In the United States today, pneumococcal vaccine coverage is suboptimal. Although inpatient vaccine screening and administration are recommended, hospitalization is an underutilized opportunity for vaccination.” 1 “Up to one in five people in the United States get influenza every season. Each year an average of approximately 226,000 people in the U.S. are hospitalized with complications from influenza and between 3,000 and 49,000 die from the disease and its complications. Combined with pneumonia, influenza is the nation’s eighth leading cause of death. The influenza vaccination is the most effective method for preventing influenza virus infection and its potentially severe complications. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons six months of age or older.” 2 The graphs on page 17 show UMMC’s compliance with appropriately assessing patients and vaccinating when indicated for the influenza and pneumococcal vaccines. We still have not reached our goals of achieving full reimbursement, nor are we offering protection to our patients.
With influenza season fast approaching, here is a quick review of what you need to know for influenza and pneumococcal vaccine assessments and documentation: ◗◗ ALL inpatients must be assessed for the vaccines, even if length of stay is less than 24 hours; ◗◗ Check immunizations section from main menu (Powerchart) to view previous vaccinations; ◗◗ If a patient is unable to answer questions regarding their pneumococcal/influenza vaccine status, check with family; you can also use records from other facilities if the patient is a transfer. If still unable to determine vaccine status, and the patient is a candidate for the vaccine per the assessment (meets the inclusion criteria and does not meet any of the exclusion criteria), order the vaccine and administer. If patient is a candidate for the vaccine per the assessment, but is critically ill or febrile, the vaccine can float along on the eMAR until the patient is no longer critically ill or febrile. Please note that critically ill and febrile status must be supported by documentation in the medical record. ◗◗ If the original vaccine assessment in the intake/triage needs to be changed, use a new immunization assessment form from ad hoc charting. Changing the original assessment in the intake/triage can cause incorrect messages in the vaccine columns on the quality dashboard. ◗◗ Do not wait until discharge to give the vaccine, unless there is a medical reason documented in an eMAR progress note (febrile, critically ill, etc.). This must be supported by other documentation in the medical record. ◗◗ If a physician wants to delay giving one of the vaccines for a specific reason, document the name of the physician and the reason in an eMAR progress note. ◗◗ If a physician does not want the patient to receive the vaccine at all during the admission, ask the physician to discontinue the order for the vaccine. Do not ask the physician to discontinue the vaccine for temporary delays in giving the vaccine. ◗◗ If the vaccine is not given, sign it off as not given and document the reason why on the eMAR (refused, was given it in the past for pneumococcal vaccine, or during current flu season for influenza vaccine). ◗◗ If patient is being discharged to hospice, the vaccine still needs to be offered if the patient is a candidate by the assessment. The patient or the family member can refuse the vaccine if a candidate. For questions about influenza and pneumococcal vaccine assessment and documentation, please contact Patty Dumler at pdumler@umm.edu. continued on page 17.
news &views Core Measures: Flu Season, continued from page 16.
UMMC Monthly Pneumococcal (PN) Vaccine Core Measures Data
UMMC monthly percent compliance PN Vaccine TJC Benchmark PN Vaccine National Average 2Q 2013 CMS Benchmark PN Vaccine National Average 7/1/12–6/30/13
UMMC Monthly Influenza Vaccine Core Measures Data
UMMC monthly percent compliance Flu Vaccine
UMMC QBR Benchmark Flu Vaccine 2013
UMMC QBR Threshold Flu Vaccine 2013
References 1. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-0114 (1Q14) through 12-31-14 (4Q14) (IMM 1.pdf) http://www.jointcommission.org/specifications_ manual_for_national_hospital_inpatient_quality_ measures.aspx 2. Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-0114 (1Q14) through 12-31-14 (4Q14) (IMM 2.pdf) http://www.jointcommission.org/specifications_ manual_for_national_hospital_inpatient_quality_ measures.aspx
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Sustaining a Successful Nurse Practitioner Partnership Carmel McComiskey, DNP, CRNP, FAANP, director of nurse practitioners and physician assistants; and Sara Reynolds, BA, project specialist, Clinical Practice and Professional Development
For the seventh year in a row, the University of Maryland Medical Center (UMMC) hosted a site visit for nurse practitioner (NP) students from Sungkyunkwan University (SKKU), an affiliate of the Samsung Medical Institute and a top-ranking academic medical school in South Korea. Carmel McComiskey, DNP, CRNP, FAANP, has again partnered with Sue Song, PhD, APRN, clinical instructor at the University of Maryland School of Nursing, to maintain this valuable partnership. In May 2014, SKKU sent 23 nurse practitioner students to UMMC for a week-long site visit. This was a highly selective process for the NP students and it was a privilege for them to have been chosen. It was the largest group the medical center had ever hosted. “It was an excellent experience for the Korean nurse practitioner students,” Song said. “University of Maryland Medical Center nurse practitioners inspired and motivated Korean visitors to have a clear vision for their professional career. They are still developing NP roles and scope of practice in Korea and this was their one and only opportunity to partner in learning. They were so appreciative of having that opportunity at UMMC.” The students spent their first morning at the Department of Veterans Affairs Medical Center and then traveled next door to UMMC. Their first stop was at the MASTRI Center, where Deb Schofield, DNP, CRNP, and her staff showcased the technology of the simulation lab. The program opened with a welcome address by McComiskey that summarized the advanced practice nurse’s (APN) role in the United States. That afternoon, with the help of a translator who summarized the concepts, the NP students listened to presentations that highlighted different aspects of APN scope and standards in the U.S. Kristin Seidl, PhD, RN, focused on UMMC’s Magnet® Journey; Carol Wade, MS, CRNP, presented the results of her survey, Improving our MD/NP Relationships; Schofield showcased Advanced Practice Nursing Outcomes; Lynnee Roane, MS, RN, presented Nursing Research & Evidence Based Practice at UMMC; and, finally, McComiskey spoke about Process Improvement and the APN Role, showcasing the work of Shari Simone, DNP, CPNP-AC. The first day concluded with a tour of UMMC. The tour was hosted by members of Clinical Practice and Professional Development, who took them to many locations throughout the Medical Center, including the trauma resuscitation unit, the helipad, the patient placement center and the general operating rooms. Cameras and phones were used during the stop at the helipad as the students loved taking pictures of themselves and the views of downtown Baltimore. The SKKU NP students spent the remainder of their week in clinical rotations on units that were chosen specifically to match their clinical interests. A number of enthusiastic preceptors welcomed students into areas from the medical intensive care unit (MICU), oncology/pain/palliative care, pediatrics/obstetrics/neonatal intensive care unit (NICU), surgery, cardiology, surgical intensive care unit (SICU) and the neurocare intensive care unit (neuro ICU). continued on page 19.
Preceptors included: MICU Team John Hagan, MS, CCRN, CRNP-AC Lou Ellen Lallier, MS, APRN-BC Oncology/Pain/Palliative Care Patty Casper, MS, RN, CRNP Nancy Gambill, MS, CRNP Madelyn Hirsch, CRNP Mindy Landau, MS, CRNP Phoung Nguyen, MS, CRNP Kim Quinn, MSN, APN, ACNP, ACNPC, CCRN Michelle Turner, MS, CRNP Pediatrics/Obstetrics/NICU Mary Connolly, MSN, CPNP Diane Keegan Wells, MSN, CPNP-AC Surgery Amy Charvat, MS, AG-ACNP, CCRN Barbara Miller, MS, CRNP Carolyn Ramos, MS, CRNP Cardiology Jee Young Choi, MSN, CRNP Michelle Lemm, MSN, ACNP-BC Kim Reck, MS, CRNP Amanda Walther, MS, CRNP Susan Yi, MS, CRNP SICU Nora Dunlap, MS, ACNP Dawn Silverman, MS, ACNP, C-CNS Neuro ICU and Neurosurgery Service Colleen Gaffney, MS, CRNP Rachel Hausladen, CRNP, MSN Joseph Haymore, MS, RN, ACNP-BC Rebecca Horrell, AG-ACNP, CNRN Emily Kay, MSN, AG-ACNP Joanna Kim, MSN, AG-ACNP Julie Wubs, MSN, CRNP
news &views Nurse Practitioner Partnership,
continued from page 18.
Left: Korean nurse practitioner students share their nursing spirit with their UMMC colleagues. Below left to right: Carmel McComiskey, DNP, CRNP, FAAN; Phuong H. Nguyen, MS, CRNP; visiting Korean nurse practitioner student; and Sara Reynolds, BA
The week concluded with a special ceremony, where students received a certificate of attendance from McComiskey and Song and posed for many photographs to remember their experience with the team. The students provided overwhelmingly positive feedback for the week that they spent at UMMC. Some examples of comments from SKKU student evaluations include the following:
“UMMC NPs were so proud of what they do – being responsible for their treatment decisions in their practice.”
Scott Taylor, MS, CRNP (2nd from left), and visiting nurse practitioner students from Korea
“I am impressed by their supportive environment. The culture among the NPs is supportive, caring, helpful and creating a learning environment for each other.” “I couldn’t help but notice that the UMMC NPs were so kind, pleasant and took the time to explain things to us even though they were so busy with a patient. They were able to maintain their professionalism even though they were in a stressful situation.” Every year the UMMC team looks forward to hosting our Korean colleagues. It is a meaningful learning opportunity for both visitors and staff. UMMC is grateful for this collaborative relationship and for the opportunity to showcase our practices. The NPs are honored to host this visit and proud they can share their passion for excellent patient care with others.
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22 South Greene Street Baltimore, Maryland 21201 www.umm.edu
Clinical Practice Update NEW! Adult Titration Dose Protocols In order to avoid nursing scope of practice issues, a TITRATION DOSE PROTOCOL has been established to guide the use of medication infusions. See MM-003 C for full table and additional instructions. Titration of Adult Infusions Agent Usual Dose Range
Initial Infusion Rate Change
Maximum Rate*
Titration Endpoint
Weaning
Opioids and Sedatives Dexmedetomidine 0.2 – 1.5 mcg/kg/hr Onset: 5 – 10 min (max effect 15 – 30 min) Duration: 2 hrs Fentanyl 25 – 300 mcg/hr Onset: 5 min Duration: 30 – 60 min Hydromorphone 0.1 –2 mg/hr Onset: 5 – 10 min Duration: 4 –5 hrs Midazolam 1 – 20 mg/hr
Start at 0.2 mcg/kg/hr (No loading dose or bolus due to concern for hypotension or bradycardia)
RASS 0 to -2
Rate Change: 0.1 mcg/kg/hr every 10 min
Start at 50 mcg/hr
300 mcg/hr
Rate Change: 50 mcg/hr every hour
Start at 0.5 mg/hr Rate Change: 0.5 mg/hr every 2 hours
Start at 1 mg/hr
Onset: 1 – 5 min Duration: variable
Rate Change: 1 mg/hr every 2 hours
Propofol 10 – 60 mcg/kg/min
Start at 10 mcg/kg/min
Onset: 30 sec Duration: 3 – 10 min
1.5 mcg/kg/hr
Rate Change: 5 mcg/kg/min every 30 – 60 minutes
RASS 0 to -2 Pain level < 4
RASS 0 to -2 4 mg/hr Pain level < 4
20 mg/hr
RASS 0 to -2
60 mcg/kg/min
RASS 0 to -2
75 – 100 mcg/kg/min (for ICP mgmt only)
ICP < 20 mmHg
For RASS -3, decrease by 0.1 mcg/kg/hr every hour as tolerated until goal RASS
50 mcg/hr every 2 hours to maintain pain level < 4
0.5 mg/hr every 2 hours to maintain pain level < 4
1 mg/hr every 2 hours as tolerated until goal RASS
5 mcg/kg/min every 30 – 60 min until goal RASS
IMPORTANT FACTS FOR NURSES REGARDING THE TITRATION PROTOCOL: Titration protocol MUST be ordered and MUST be followed unless otherwise specified in provider orders. A copy (form #PO96 in FormFast) must be placed in the patient’s medical record (under the orders section), including patient identifiers or patient sticker. If the prescribed therapeutic endpoint cannot be reached while remaining within the protocol limits, contact the provider for new orders.