News & Views

N E W S & V I E W S

Winter 2012

Patient Satisfaction: Just How Important Is It? By: Kerry Sobol, RN, MBA, Director, Patient Experience/Guest Services and Commitment to Excellence and Paul Thurman, MS, RN, ACNPC, CCNS, CCRN, CNS, Shock Trauma Center Customers today know what they are looking for when making purchases. They seek advice from friends, family, and the internet. This makes customer service one of the most important aspects of any business. Healthcare is no exception. Patient satisfaction is a key indicator of the Medical Center’s performance.

a mechanism to objectively compare notes on what is important to patients, and how they rate the care they have received. These results are reported publicly on www.hospitalcompare.hhs.gov.

In addition, starting in 2013, these scores will be tied to reimbursement from Medicare and Medicaid.

Many of the Medical Center’s inpatient, ambulatory, and support areas survey their customers. Patients are surveyed by outside companies through a random selection process of patients who are 18 or older. In addition, many people within the Medical Center are devoted to addressing concerns of patients and their families.

Hospitals and care providers across the country are focused on improving outcomes related to patient satisfaction. All aspects of what the patient and family expect when they receive care is referred to as the “Patient Experience.” The Institute for Healthcare Improvement (IHI) recently completed in-depth research in this area to identify primary and secondary drivers of exceptional patient and family inpatient hospital experiences.

The research revealed that the drivers of an exceptional patient experience are founded on a commitment to patient and familycentered care and have the following characteristics: • People are treated with dignity and respect; • Healthcare providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful; • Patients and family members build on their strengths by participating in experiences that enhance control and independence; and • Collaboration among patients, family members, and providers is evident throughout the hospital as well as in the delivery of care.1

A standardized approach developed by the Centers for Medicare and Medicaid Services (CMS), called HCAHPS or the Hospital Consumer Assessment of Healthcare Providers and Systems, is used to survey patients. These survey questions were developed to help consumers make informed decisions about their healthcare providers and hospitals. The questions for ambulatory, emergency IN THIS ISSUE... rooms, same Patient Satisfaction: Just How Important Is It? 1,4 day surgery, Lisa Rowen’s Rounds 2,5 and inpatients Revised Order Sets 3 vary according May Is Cardio-Vascular and Stroke Awareness Month 3 to the type of UMMC and Drexel University Online Form Educational Alliance 5 service rendered.

Being Green on Greene Street 6,7 Healthcare Interdisciplinary Performance Innovation 7 providers that Enlightening Visit to the UMMC Dietary Department 8 receive reimbursement from Hypertension Management Across the Outpatient Continuum 9 Medicare or Meet the UMMC Nurse Ambassadors 10,11 Medicaid are Rapid Response Team Implemented at UMMC 12 required to use Flexible Visitation Takes Off at UMMC 13,16 this survey and New Guidelines - Patients Leaving Units Independently 14,15 report results to Trends In Nursing Practice Conference 15 the government.

Certification Corner 16 This process Honorable Mention 17 provides conCore Measures 18 sumers, as well We Discover 19 as hospitals and Do Not Crush Hazardous Medications 20 providers, with NEWS & VIEWS

One method that the Medical Center intends to utilize to influence the patient experience and satisfaction is “hourly rounding.” Hourly rounding is a purposeful, autonomous nursing intervention, providing a surveillance mechanism to keep patients safe and comfortable by proactively meeting their needs.

It is intentionally checking on patients at regular intervals, during which nurses engage patients by checking on the “4 P’s”: • Pain; • Positioning; • Personal needs (elimination); and • Proximity of personal items.

To continue, see Patient Satisfaction on page 4

News & Views on the UMM Intranet: intra.umm.edu/ummc/nursing_dept/newsnviews.htm

1

Lisa Rowen’s Rounds Hourly Rounds Across our nursing care areas, we’ve had a lot of conversation about hourly rounds. To be clear, I am speaking of the intentional and purposeful checking in on patients at regular, hourly intervals, separate and different from all the times nurses and nursing staff go in and out of a patient’s room or are at the bedside. While making hourly rounds, the goals are to reinforce our concern for and carry out activities to ensure the patient’s comfort and proper positioning; assess, provide, and evaluate effective pain control; assess and implement necessary toileting or elimination activities; and ensure the patient’s desired possessions – and the call light -- are within reach.

Why are we talking about hourly rounding? The evidence indicates this type of nursing practice yields promising outcomes.

Halm (2009) performed a review of all evidence from research and

quality improvement studies about hourly rounds.1 After searching MEDLINE and CINAHL, she found reports of 11 studies of hourly rounds that were included in the analysis. Not all of the 11 studies analyzed the same indicators, but enough did to see a trend.

In 5 of the 6 studies that examined use of call lights, use of call lights was reduced when nurses conducted hourly rounds. Fall rates were reduced in 7 of 9 studies in which falls were evaluated, and a reduced use of restraints and sitters occurred when hourly rounds were instituted. In 8 of 9 studies, overall scores for patient satisfaction rose, as did the scores for likelihood of recommending the hospital. In addition, scores also improved for nurse-sensitive quality indicators of patient satisfaction, such as anticipation and attention to personal needs, timeliness of nurses’ response, and management of pain.

The data tell a compelling story, the kind of story we would like to see unfold at the Medical Center. Halm concluded that available evidence indicates making hourly rounds is appropriate, safe and useful for practice.2 See Table 1.

Table 1

*Used with the permission of American Journal of Critical Care Nursing

To continue, see Hourly Rounds on page 5

2

NEWS & VIEWS

News & Views is published bimonthly by the Department

of Nursing & Patient Care Services of the University of Maryland Medical Center Scope of Publication • Clinical and professional nursing practice in inpatient, procedural, and ambulatory areas that is evidence-based, innovative, and outcomes driven.

• Focus on divisional, departmental, and/or organizational strategic goals.

Guidelines for Article Submission 1. Times New Roman - 12 pt black font only.

2. Length - three double spaced, typed pages maximum.

3. Include name, position title, credentials, and practice area for all writers.

4. Credentials must be provided for anyone named in the article.

5. Proofread article for spelling, grammar, and punctuation before submitting.

6. Provide photos in .jpg format.

7. Send completed articles via e-mail to anaunton@umm.edu by the due dates noted in the box below.

8. Editor will seek expert review of articles to verify and validate content.

9. Submit trend data in graphic format with labeled axes.

2012 ISSUE

Winter

Spring

Summer

Fall

2012 DUE DATE Feb 13 April 30 July 30 Oct 29

Please send all News & Views articles to Anne Naunton via email anaunton@umm.edu. Please follow the submission requirements that are published in each issue of News & Views.

Editor Anne E. Naunton, MS, RN Professional Development Coordinator Clinical Practice and Professional Development Editorial Board Lisa Rowen, DNSc, RN, FAAN Senior Vice President and Chief Nursing Officer Nursing and Patient Care Services Ann E. Regier, MS, RN Director Clinical Practice and Professional Development Kristin Seidl, PhD, RN Director of Nursing Outcomes, Research, and Evidence-based Practice Angela Sintes, MS, RN, CNL Clinical Education Specialist Clinical Practice and Professional Development Susan S. Carey, MS Professional Development Coordinator Clinical Practice and Professional Development

Revised Order Sets Reflect Current Evidence and Support Nursing Practice By: Karen A. McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN In the spring of 2011, the University of Maryland Medical Center received feedback from reviewers evaluating our Joint Commission readiness that we needed to ensure that nurses were practicing within their scope, as defined by the Maryland Board of Nursing. A task force was convened to identify and remedy computer order-entry issues that contributed to nurses potentially practicing outside their scope. Dr. Abel Joy and I were tasked with leading this Order Management Workgroup that was made up of IT representatives, pharmacists, a physician, and nurses.

Our first task was to convene a larger group of prescribers and nurses to brainstorm where there were opportunities for improvement in the prescribing and order-usage process. After compiling a long list, it was felt that the intervention with the most impact was to have our power plans updated and revised to include statements that reflected the current evidence and supported nurses’ practice.

The owner of each power plan and the Director of Nursing for the department that owned the plan were tasked with convening a multidisciplinary group that included nurse practitioners, nurses, pharmacists, and individuals from any relevant ancillary service to provide a comprehensive review of the plan. These groups were instructed to construct clearly defined orders that allowed nurses to act in response to emergent situations. For example, for new-onset arrhythmias, obtain a 12-lead ECG and notify the provider. They were also to include orders that provided for the implementation of organizational standards (e.g. routine Infection Control surveillance cultures).

As a result of this process, many of the current power plans have undergone revision and have been submitted to ITG. Following review of the proposed changes, IT will make the revisions and the completed power plans will go back to the owners for final approval. In the near future, you will see revisions to the power plans that will enhance the ability of every nurse to practice within their scope of practice.

May Is Cardio-Vascular and Stroke Awareness Month By: David G. Hunt, MSN, RN, Director of Nursing and Patient Care Services for Cardiac Care and Radiology This May, the staff of the Heart Center and Stroke Center at UMMC will be celebrating “Cardio-Vascular and Stroke Awareness Month.” The goal is to provide our staff with exposure to many activities that will enhance their knowledge and understanding of heart and stroke risk, as well as do something healthy for themselves on-site. It also outlines our partnership with the American Heart/Stroke Association, which supports us in our work each year.

Heart disease and stroke account for the number one and number three killers of Americans each year. During the month, events will focus on education, health screening, healthy eating, exercise, and relaxation. These activities will include: • • • • •

Lunch and learns; Weekly health screenings; High-school champion jump rope team display; Healthy eating “cook-off” event; Tranquility Tuesdays – opportunities to relax and receive Healing Touch and Reiki; and • Get-Fit-Friday walks.

All events are free to staff. There will be more information to come on how to signup and participate. A calendar will be available on the UMM intranet that highlights many of this year’s events. If you would like more information, please contact David Hunt via email dhunt@umm.edu.

WINTER 2012

3

Patient Satisfaction from page 1 In addition, one final question to the patient and family should be, “Is there anything else I can do for you?” The act of making hourly rounds can be viewed as a bundle of interventions that promote the comfort and safety of patients. In addition, hourly rounding increases efficiency and organization of workflow, as staff are able to anticipate and attend to patients’ needs. This is because it is a proactive instead of a reactive approach.

Hourly rounds help manage patients’ expectations. An illness causes uncertainty that spreads into the patient’s life and breaks down the individual’s point of view and reality. Uncertainty becomes a driving force and is accepted as reality. Hourly rounding relieves some of that uncertainty. Patients become less anxious about getting their needs met, as they learn to trust the process. Patient satisfaction with nursing care and the facility increase in response to the intervention. The practice of attending to the patients’ comfort, safety, and environmental needs prevents adverse events like falls, pressure ulcers, or unrelieved pain.

A clinical evidence review2 found the following for inpatients: • In 5 out of 6 studies (83%), use of call lights decreased; • A 20% reduction in the distance that staff walked and fewer call lights; • Fall rates were reduced in 7 of 9 studies (77%); and • In 8 of 9 studies (88%), researchers discovered improvements in overall patient satisfaction and likelihood of recommending the hospital, as well as, satisfaction with anticipation and attention to personal needs, timeliness of nurses’ response, and management of pain.

In emergency departments, clinics, and other outpatient settings, nurses and patient care staff can use a similar approach, but focus on three important aspects of care in these areas known as the PPD approach – Pain, Plan (of care), and Delays. In other words, hourly rounding will be implemented in any area where direct patient care is delivered. In these areas, specifically focusing on pain, the plan, and any delays, will provide the staff perspective on how their patients are feeling. More importantly, this approach will let patients know that they are receiving the necessary attention by a caring staff.

In 2006, the Studor Group completed a study that looked at eight rounding behaviors in 32 emergency rooms across the country. The results of rounding revealed the following: • Reduced the number of patients who left without being seen by 24.3%; • Decreased the number of patients who left against medical advice by 22.6%; • Reduced call light usage by 34.7%; • Reduced the number of families and patients who approached the nursing station by 39.5%; and • Patient satisfaction increased between 5 and 20 mean points during the studies.3

4

NEWS & VIEWS

Many nurses would agree that these activities are the equivalent of “Nursing 101,” representing good basic nursing care. Given this fact, implementation of hourly rounding can be challenging. Some nurses believe that the scripting is too rehearsed.4 However, this “language” is intended to standardize practice and help patients know what to expect from rounds. Nurses can customize how they ask patients about the 4 “Ps” and take ownership of their practice. Nurses in critical care may make rounds on families to show concerns for their needs. Acuity levels provide additional challenges.5 Hourly rounding does not replace critical thinking. For example, at times, it may be appropriate for nurses to remain with a sick patient to guarantee positive outcomes, forgoing routine rounds for a patient who is in stable condition. It is important in these situations to communicate with other team members to continue hourly rounds on all patients.

Rounding can be delegated to unlicensed assistive personnel (UAP). The task can be split so that the nurse rounds on even hours, and the UAP rounds on odd hours. This is effective as long as there is good team communication and all patient needs are met, especially those that are not within the UAP’s skill set.

Documentation of rounds is a challenge because it is felt to be a burden and extra work for overloaded patient care staff members.6 Although logs of documented rounds drive accountability, they may also breed opposition and wavering adherence between team members.

Hourly rounding is an important intervention in the nurse’s toolkit to improve patient outcomes. There can be challenges to implementation; however, there are rewards for the patient, the nurse, and the hospital as a whole. As hourly rounding continues to be incorporated as a consistent routine at the Medical Center, careful attention must be paid to the response from patients, families, and staff.

Hourly rounding is a comprehensive process that will directly influence all patients – inpatient and outpatient. The consistency in practice, and in what the patients and families see and hear, in any care setting, will foster a sense of teamwork and caring that will have a positive long-term impact on improving patient satisfaction. _______ Leaders’ Role in Patient Experience, Hospital leadership must drive efforts to better meet patients’ needs. Healthcare Executive, July/August 2011.

Halm, M. Hourly Rounds: What does the evidence indicate? AJCC. 2009. 18(6).

3 http://www.studergroup.com/ED_study 4,5,6 www.jenonline.org. January 2012, volume 38, issue 1.

1

2

UMMC and Drexel University Online Form Educational Alliance Through the Middlesex Hospital-Drexel University Online partnership, UMMC employees and their family members are entitled to a 10-25 percent tuition reduction on Drexel’s distinguished degree and certificate programs.

Ranked among “America’s Best Colleges 2012” by U.S. News & World Report, Drexel’s top-rated online programs help you stay ahead of the curve in your field. Choose from more than 100 online programs, including the RN to BSN, MSN and DNP programs within nursing. Other programs include Project Management, MBA Anywhere™, MS in Clinical Research Organization and Management, MS in Healthcare Informatics and many more.

Get Started Today! Application deadlines are approaching. Complete your no-cost application today.

Be sure to enter your partner code “UMMC” to receive your full tuition reduction.

Please visit www.drexel.com/ummc for complete details on your partnership benefits and educational opportunities available with Drexel Online.

If you have questions, please contact your Partnership Liaison today.

Dan Henner | 215-895-0951 | drh67@drexel.edu | www.drexel.com/ummc

Hourly Rounds from page 2 In the practice of nursing, purposeful hourly rounds can be a fresh twist that can structure the nursing process to actively engage patients and their families. So while the evidence supports the practice, why are hourly rounds somewhat controversial?

I’ve heard nurses say they do not need to make hourly rounds because they are always at the bedside. Some say they don’t want additional documentation responsibilities. Others have said they don’t like the “scripted” dialogue that accompanies purposeful hourly rounds -- that this dialogue can feel rehearsed or stilted. The fact is, the language we use with our patients in describing hourly rounds and their purpose is important not only to standardize the practice and let patients and families know what to expect, but also to communicate our genuine care about the patient. While we need to include some specific language, though, it is possible and preferred to make hourly rounds personal for each patient.

Many of us would agree that if we were hospitalized on an inpatient unit, we and/or our family members would appreciate the nurses and

patient care techs and assistants coming into our rooms to address our pain, positioning, personal needs (elimination) and the proximity of our personal items. If we were in the ED, procedural and ambulatory areas, we’d appreciate rounds that addressed our pain, plan of care and any delays. These types of hourly rounds, separate and different from going into a patient’s room to deliver medications, change a dressing, monitor vital signs, or perform a physical assessment, engender the feeling of being cared about in a sincere and personal way. These regular visits reassure patients and families that in addition to the specific duties we go in and out of the room to perform, we also schedule time to look at the patient in a holistic way to make sure all their needs are addressed.

Over the next several months, you will hear and learn more about performing consistent, purposeful hourly rounds. I hope you will agree they are valuable and our patients deserve nothing less.

_______

Halm, M.A., 2009, Hourly Rounds: What Does the Evidence Indicate? American Journal of Critical Care, 18:6, pp. 581 – 584.

2 Halm, M.A., 2009, Hourly Rounds: What Does the Evidence Indicate? American Journal of Critical Care, 18:6, Table 1, p.582.

1

WINTER 2012

5

Being Green on Greene Street Where We Have Been and Where We Are Going

By: Denise B. Choiniere, MS, RN, Interim Director, Facilities Services, Sustainability Manager Some may look at the University of Maryland Medical Center, which uses enough electricity in one year to power 6,846 homes and generates more than 3,013 tons of trash each year, and see a black hole of unavoidable waste. However, Denise Choiniere, Sustainability Manager, and the Green Team see it as an opportunity to decrease our environmental footprint, while making our work environments safer for us and our patients. Since the inception of the Green Team six years ago, much has been done to achieve these goals and much more is in the works.

Waste Reduction It is a well-known fact that you cannot track what you do not measure. Therefore, with the signing of our new waste contract in 2009, and implementation of true waste separation, we began tracking our waste. In 2009, 60 percent of our waste stream left our facility as regulated medical waste (RMW) for incineration. Knowing that medical waste incineration is a leading source of dioxin, mercury, lead and other dangerous pollutants that threaten human health and the environment (http:// www.noharm.org/all_regions/issues/waste/), the Green Team set out to decrease this number.

Since that time, we have decreased our RMW to 27 percent of our waste stream. Because disposing of RMW costs five times more than disposing of clear bag waste, we should all be paying attention to where we throw our trash. While we have made great improvements, and have saved a substantial amount of money, we can do even better. The hospital’s goal is to decrease our RMW to 10 percent of our waste stream, and the Green Team needs your help!

Please know where to throw. The definition of RMW states that items must be soaked and saturated with a bodily fluid to be

considered RMW. This means that packaging and isolation gowns do NOT meet the definition and should be disposed of in a clear bag. By abiding by this definition, the goal is easily achievable.

The Green Team is also working with Infection Prevention, Housekeeping and Hospitality Services, and 10 East to pilot a new RMW collection program to help drive our numbers down.

Planning for an additional pilot project is under way to meet our goal of decreasing RMW, which is by increasing recycling. Thank you to North 10 West and Select Trauma Critical Care for agreeing to pilot recycling from patient rooms. The program will be an attempt to add to the convenience of recycling for staff, patients and family members and will have a positive impact on the environment.

Energy Conservation You may have noticed the emphasis on natural light instead of artificial light in the hospital atriums. Last summer, the Facilities Department spent rebate money earned from BGE to decrease unnecessary lighting and upgrade inefficient lighting. When the project was complete, 352 lights were turned off when natural lighting was sufficient, 420 lights were put on motion sensors, 102 lighting fixtures were upgraded and 42 lights were eliminated. The project team anticipates additional rebate money from BGE for these upgrades, and plans to continue installing more sensors with the rebate money. UMMC received its 3rd Trailblazer award from Maryland Hospitals for a Healthy Environment (MDH2E) for this project, making UMMC the only hospital to win this award for three consecutive years.

You can help conserve energy and decrease money spent on utility bills by turning off lights, shutting down computers, taking the stairs, using the revolving doors and turning off air and gases when not in use.

Alternative Transportation You also may have noticed the 43 new two-bike post racks and two new multi-bike racks installed by the Gudelsky and North Hospital entrances. Why not take advantage of this year’s unseasonably warm and dry winter and grab that helmet, high-visible clothing and ride your bike to work? Not only will you reduce the amount of CO2 emissions in the air, but you also will improve your health.

Also coming in April 2012 to the Medical Center Garage will be 34 preferred parking spots for fuel-efficient vehicles. Beginning in mid-April, owners with eligible vehicles can obtain a parking sticker from the parking office that will allow them to park in these reserved spots.

To continue, see Being Green on page 7

6

NEWS & VIEWS

Interdisciplinary Performance Innovation By: Shawn Hendricks, MSN, RN, Nurse Manager, 10 East

Healthcare organizations need to be more efficient, effective and safe. Performance innovation is a strategy used at UMMC to describe the process of maximizing the parts of any process and eliminating waste to make the patient experience safer and more satisfying. Nurses from 10 East led a collaborative group of professionals from all disciplines and departments to address care gaps, methodically determine root causes, and identify solutions through the use of “lean” tools and “A3 thinking.”

Several opportunities for improvement were identified and addressed through Rapid Improvement Events (RIE). An RIE is a set of experiments that are tested in a short period of time -- in our case, five days. We tweaked, tested, refined and sometimes changed the process during that intense five-day period. A significant part of this process included data collection and outcome analysis.

Here are some processes that were improved on 10 East through the RIE approach: Discharge Process • Planning order placed 24-36 hours prior to discharge • Discharge order placed prior to discharge • Patient discharge by 2 p.m.

Team and Patient Communication Process • Relationship-Based Care (RBC) board in each patient’s room redesigned to provide information about the care team and plan of care • Standardize text paging format • Utilization of the Resident Sign-Out Note by 5 p.m.

• Ensure correct intern name and pager numbers are updated in “admit to” order

In regard to the RBC board, 10 East, along with an interdisciplinary team, recognized that it was difficult to identify the nurse and physicians covering a patient at any time. This resulted in a lack of coordination in the interdisciplinary plan of care, delayed treatment, unanticipated conflicts in scheduling tests, late afternoon discharges, and decreased patient and staff satisfaction.

Through our RIEs, 10 East nurses led collaborative experiments in all of these areas and achieved positive results. The emphasis on sustainability and continuous improvement resulted in effective care coordination, increased safety, timely discharges, and improved patient/staff satisfaction.

The next step is disseminating what we learned to other units within the hospital. Each unit will then adapt these new processes to their environment. This work includes choosing a champion, collecting data for 30 days, and re-evaluating data for further improvement.

Being Green from page 6 funding to start an electronic balance transfer (EBT) program, allowing the market to accept food stamps, now referred to as Supplemental Nutrition Assistance Program (SNAP). The goal is to provide a venue for the local community to purchase fresh fruits and vegetables, an opportunity that is lacking in our neighborhood. With the addition of EBT, the market also will be able to accept credit and debit transactions for the first time. The market, located in the Plaza Park across from the main entrance of the hospital, is held on Tuesdays from 10:00 a.m. to 2:30 p.m., Spring through Fall.

Earth Day Mark your calendars. The Green Team will be celebrating Earth Day, Friday, April 20th in the Weinberg Atrium.

Stay tuned for a finalized list of events.

University Farmers Market The University Farmers Market will start its 4th season this spring. This year you can expect fresh local fruits, vegetables, breads, soups, jams, marinades and other prepared hot foods. This year’s organizers are currently seeking

The Green Team meets the last Thursday of every month from 2-3pm in the 29 S. Greene St. Building in the 6th floor conference room. Please email Justin Graves, Green Team Chair, at jgraves2@umm.edu, for more information if you would like to get involved.

WINTER 2012

7

Reflections on an Enlightening Visit to the UMMC Dietary Department By: Christie Collins, BSN, RN, CCRN, SCN1, MTCC and Amira Lawrence, BSN, RN, CNRN, SCN1, NTIMC It is not often in our busy world that we are able to consider, much less visit, the workings of other departments, which are so much an integral part of patient care. On Sept.15, 2011, the STC Executive Council had the pleasure of visiting the UMMC dietary department. We were given the opportunity to learn just how much work and effort is put forth by this dedicated group to provide nutritious and delicious meals to the patients, visitors and staff of the Medical Center.

The tour began in the dietary office, where we encountered the first of many surprises. Here we learned that one of two clerks starts work at 4 a.m., coming in to print and review the diet slips that identify what foods each patient will receive on his or her tray. The process is complicated by the fact that Cerner, the clinical information system, and the diet computer system do not “talk” to one another; this requires any comments placed in an order to be manually transferred to the dietary computer system. Another problem occurs when a patient is made NPO in Cerner because all previous preferences disappear. As a result, when the patient is placed back on a particular diet, any preferences need to be re-written in the order and called to the dietary department.

From the office, we proceeded to the tray line. This is where each tray begins its journey from condiments to entrees before being delivered to each floor. The amount of production that is accomplished in such a limited space is truly incredible. Each station (condiments/utensils, sides, entrees, drinks) is operated by a staff member responsible for ensuring that the correct items are placed on the tray according to the slip provided by the dietary clerk. This efficient operation is complicated when the team is down a member; there is no supplemental or on-call staff to fill the gap left by a member who may be absent.

More evidence of how this department does so much with so little was obvious in the area of food preparation. Fresh ingredients are prepared the day before, covered and placed on trolleys. In the morning, the cooking staff has all ingredients readily available. This includes premeasured spices, vegetables and meats that are combined into a wonderful meal that tastes home-cooked.

We were surprised and delighted to learn that all of the soups and desserts are handmade from fresh ingredients. The cooking staff also is responsible for making all snacks for patients, as well as preparing food for catering UMMC meetings.

Looking into the future, this industrious group is pursuing an innovation in meal service. The Dietary Managers Association (DMA) is working with Mark Washenko, Food Service

8

NEWS & VIEWS

Director, and his staff on kitchen design and meal preparation in order to provide our patients with hotel-style room service. Checks and balances will be in place, and the staff will be trained, so that they will be able to assist patients with food choices appropriate for their ordered dietary needs. As an example, we were pleasantly surprised to find that this included education to patients on special diets (i.e. calorie- or sodiumcontrolled) to not necessarily restrict their diets, but to help them learn how to make wise choices that fit into their diet plan.

The revamping of food delivery will include a computer system that “talks” to Cerner, thereby improving the translation of diet orders with comments from the units to dietary.

In conclusion, we would like to thank Mark Washenko; EvaLynn Stevens, MS, RD, LDN, Assistant Food Service Director; Mary Rice, Retail Manager; Steve Mack, CEC, Executive Chef; and all of the dietary staff for their hard work and commitment to providing delicious, well-prepared meals to patients, visitors and staff at UMMC. We appreciate the time they took to let us see what wonderful work they are doing with limited resources.

We look forward to the coming changes and will do our best to aid in their current efforts.

Here are suggestions for nurses as a result of our experience: • Be patient and understanding--the dietary staff is working hard under less than ideal conditions. They are committed to serving the patients, visitors and staff of UMMC! • Explain to physicians why new diet orders need to be entered in a timely manner.

• Be understanding when calling the dietary department and no one answers the phone. The clerk has to physically walk new slips out to the tray line, answer numerous calls and check that information from Cerner is translated to the dietary computer.

• Advocate for dietary when patients/families are upset that their meals or preferences are not what they ordered and when physicians do not understand why they have to re-enter all the previous information.

• Remember that the dietary department is working with limited staff. When staff is absent, production will slow down. However, everyone in dietary is committed to continuing to provide high-quality service.

Hypertension Management Across the Outpatient Continuum By: Jacqueline Rodriguez, BSN, RN, Senior Quality and Compliance Coordinator, Ambulatory Services Hypertension, the “silent-killer,” affects 1 in 3 adults nationwide.1 Behavioral lifestyle, socio-economic status and environmental factors increase a person’s risk of developing this disease.

There are national efforts that target education, prevention, timely intervention, and management.2 The University of Maryland Medical Center has embarked on an initiative to guide clinicians in the management of hypertension across the continuum of outpatient care. A baseline survey of UMMC clinics revealed varying levels of participation in blood pressure (BP) assessment, various types of BP measurement equipment, lack of a standard technique to obtain BP readings, inconsistent communication among the clinical team, and challenges in the referral process. Consequently, a three-phase program was developed to address these concerns.

Phase one focused on two of the noted practice variations. They were: (1) varying participation in BP assessments and (2) lack of a standard technique to obtain BP readings. After a review of national appointment utilization patterns, a decision was made to include all primary and specialty services as the pilot sites for the program.

An assessment of staff knowledge of the proper technique to obtain a BP reading was completed. This prompted the leadership team to seek support from Clinical Practice and Professional Development to develop a comprehensive training program for BP measurement and competency validation. A “train the trainer” approach was utilized that incorporated pre- and post-training tests, standardized content, and real-time return demonstrations to validate appropriate BP measurement techniques. Ninety-eight percent of the clinic staff received training.

Phase two emphasized communication within the clinic and the hand-off process to the next appropriate practitioner. A pilot was conducted between September through December 2011. Based on JNCVII (a national expert panel established by the National Heart, Lung, and Blood Institute), an algorithm was implemented to assist the clinic staff in identifying abnormal BP readings

and referral suggestions. An alert tool was developed to enhance the communication between the clinic staff and the LIP during the visit. This “alert” was given to the patient at the end of the visit to serve as a reminder to follow up with an identified recommended practitioner. A Blood Pressure Detection (BPD) clinic was established for patients that needed a second blood pressure check and for patients without a primary care physician, It was noted that 157 abnormal BP “alerts” were issued in the pilot sites. This was equivalent to a 13/1000 visit prevalence rate for an abnormal BP in the medical specialty clinic and 12/1000 in the surgical specialty clinic. The average age of patients seen in the surgical specialty clinic was 48, compared to 54 in the medical specialty clinic.

The pilot program was successful in identifying patients with abnormal blood pressures that required follow-up. However, documentation in the medical record still needs to be improved. A chart audit was conducted on a sample of the patients identified during the “alert” process. Despite an “alert” being issued, only 79% of the medical records reflected the BP in the LIP visit note, and only 37% documented their intervention for the abnormal BP reading.

The rollout of phase two is planned for all outpatient sites.

Additional strategies to improve documentation compliance are underway for the upcoming months and will include collaboration with the electronic medical record team.

Phase three will incorporate more emphasis on the BPD clinic and the role of enhancing continuity and care between specialty clinics and primary care sites. The management of hypertension and updating the program with new guidelines will be highlighted. Finally, new JNCVIII guidelines will be released, and the program will continue to align with the goals and best practices of the National Heart, Lung, and Blood Institute. _______ 1 2

http://www.cdc.gov/bloodpressure/ http://www.iom.edu/Reports/2010/A-Population-Based-Policy-and-Systems-Change-Approach-toPrevent-and-Control-Hypertension.aspx

NDNQI Nurse Satisfaction Survey The annual NDNQI nurse satisfaction survey will be conducted May 7-27, 2012. The details for accessing the survey will be posted on the UMM intranet.

Survey Eligibility Criteria Included RNs: • RN or Advanced Practice RN (APRN) • Direct patient care provider - 50% or greater direct patient care responsibilities, regardless of job title • Full-time, part-time, PRN, or per-diem RN employed by hospital • Employed in unit a minimum of 3 months by the first day of your survey

Excluded RNs: • RNs in management, supervisory, or nurse education roles with less than 50% of job responsibilities in direct patient care • Agency, traveler, or contract RNs • New hires or internal transfers employed in current unit or workgroup less than 3 months • RNs on leave of absence (LOA) Please contact Anne Naunton via email anaunton@umm.edu if you have questions.

WINTER 2012

9

Meet the UMMC Nurse Ambassadors By: Alexandra Bessent, Director, Service Line Marketing This is getting personal. The newest University of Maryland Medical Center (UMMC) campaign to recruit nurses and advanced practice nurses is coming directly from the source.

Meet Cindy, Jeremy, Roseann, Robby, Tracy, June, Harriett and Kristina! This group of eight, representing RNs, NPs and other advanced practice nurses (APNs), has been tapped to serve as “Nurse Ambassadors.” They are the face of the new nurse recruitment campaign, telling their personal stories online to attract new or experienced nurses willing to make a career and life in Baltimore at the University of Maryland (UM).

This campaign is different in that it is interactive and it originates from those who know what UM is really like. Nurse Ambassadors were recruited to provide candidates for nursing positions at UMMC with diverse examples of who succeeds here.

In telling their stories and answering questions from candidates, these Ambassadors illustrate what a career at the Medical Center can offer. They serve as a real ‘connection’ for candidates.

Log onto Facebook.com/MarylandNursing and you can engage and ask questions of the Ambassadors. They are genuine. They are very real. They are sharing experiences with which nurses can relate.

Nursing leaders were asked to identify individuals who embodied what it means to be a nurse at the Medical Center. They picked people whom they described as: inspirational, an advocate for patients, trustworthy, articulate, professional, reliable, accountable, and a true leader.

Once the list was created, it was time for the Medical Center’s ad agency, SPM, to make contact with each Ambassador.

SPM originated the idea of developing the Ambassador campaign. The Creative Director spoke with each person and echoed leadership’s choices that this was indeed a dynamic and great group. Each Ambassador then needed to carve out about five hours of their day for a sit down interview on camera.

Cindy Rew, BSN, RN, can be found most days in the SICU where she is a Nurse Manager. She is an infectious leader who inspires those around her. Outside of work, she is pursuing a graduate degree and busy raising two children.

Jeremy Kirlew, BSN, RN, is the first to admit he is a bit of a technology geek. In the Cardiac Catheterization Lab, he is the go-to-guy for learning about the latest gadget or gizmo. He is a patient teacher who makes sure his colleagues understand sophisticated technology.

10

NEWS & VIEWS

Roseann Dougherty, BSN, RN, a Cancer Center nurse, is a triathlete who uses positive energy when caring for patients. Her patients and their cancer battles provide Roseann with the inspiration she needs to run, bike, and swim great distances.

Robby Klawitter, MS, CRNP, is a familiar face in the Cardiac Surgery ICU where, as a Nurse Practitioner, he plays a vital role caring for sick patients. He was one of the first NPs at UMMC, and now there are about 240 Advanced Practice Nurses. So Robby is not in the minority but amongst a great crowd.

In the Pediatric Emergency Department, Tracy Statter, BSN, RN, CPEN, is a young nurse who is making quite an impact on patient care in her few years on the job. Her hard work has earned her a promotion, clearly illustrating that doing a good job pays off.

June Guadalupe, BSN, RN, CCRN, CNRN, CEN, CMC, leads a fairly unpredictable life as a nurse in the Trauma Resuscitation Unit at Shock Trauma. He is, however, very predictable in finding time to work out at the gym and in his need to provide great patient care.

Harriett Neverdon, BSN, RN, was a little intimidated at the thought of coming to work at an academic Medical Center, but when she walked through the doors of the Neurological IMC, she knew she was home.

She received great training and her mentor in the unit has helped her to grow tremendously.

Kristina Ludwig, MSN, CRNA, is new to Baltimore and to the job as a Certified Nurse Anesthetist. She sees her new city and her new position as a great place for growth and exploration.

Nursing candidates are finding the Ambassadors and their videos through online banner ads and through a print campaign for nurse recruitment that aligns with our consumer campaign of MEDICINE ON A MISSION. Visit umm.edu/nursing and you can meet the Ambassadors and see their video stories. The ultimate goal of this campaign is to engage and encourage prospective nursing candidates to be part of the great and growing nursing environment at UMMC.

WINTER 2012

11

Rapid Response Team Implemented at UMMC By: Margie Goralski Stickles, MSN, RN, MBA, CCRN, Director of Nursing, Peri-Operative Services and Procedural Sites The “100,000 Lives Campaign” was launched by the Institute for Healthcare Improvements (IHI).1 In this campaign, six interventions were identified and encouraged to prevent harm and unplanned deaths within healthcare organizations. Rapid response teams were at the top of the list. A rapid response process had been in existence at the University of Maryland Medical Center (UMMC), but in the spring of 2011, senior leaders identified a need for additional resources to meet this IHI recommendation and expand this crucial patient safety and regulatory practice.

near future. Staff satisfaction surveys are distributed and collected, and the results are analyzed to determine opportunities for process improvements.

Data collection is an integral component of the rapid response process.

The information from the data generates targeted actions to improve patient outcomes and provide staff education. The current trends indicate that most calls occur at change of shift.

The purpose of the Rapid Response Team is to promptly detect, respond, treat, and rescue the patient who shows early signs of deterioration. The widespread acceptance by nurses, physicians, and administrators has been well established. The ability to provide a specialized team as a resource to the primary health care team has been shown to decrease cardiopulmonary arrests, decrease unplanned transfers to higher levels of care, and increase staff satisfaction.

The Rapid Response Team at UMMC comprises an advanced certified Critical Care Registered Nurse (CCRN), a critical care Patient Care Technician (PCT), and a Registered Respiratory Therapist (RRT).

Physician collaboration occurs with the primary service. The Rapid Response Team’s practice is overseen by Marjan Bahador, MD, Medical Director, and Margie Goralski Stickles, MSN, RN, MBA CCRN, Director of Nursing. The mission of UMMC’s Rapid Response Team is “to support and work collaboratively with the Primary Care Team to quickly address identified changes at the earliest opportunity and prevent further deterioration.”

The current scope of practice for the Rapid Response Team includes acute care areas, intermediate care units, and inpatients within procedural and diagnostic areas. The process begins with a call from the primary care team for any reason. Sometimes the patient’s deterioration is obvious: for example, by decreased blood pressure, shortness of breath, change in level of consciousness, or acute confusion. Other times it is difficult to identify the cause without further evaluation and resources.

The team supplies the resources to provide care for the deteriorating patient; this decreases the interruptions in the care for the other patients on the unit. Because the team has a critical care scope of practice, transports to needed diagnostics can occur appropriately without the accompaniment of the primary physician. This is a change from the past when a physician was needed to assist the acute care RN with transports.

There have been a total of 245 calls to the Rapid Response Team through 2/29/12. The calls have been categorized into the following systems: Respiratory • SOB, increased oxygen demand, decreased oxygen saturation Cardiovascular • Tachycardia, arrhythmia, hypertension, hypotension Neurological • Change in level of consciousness Gastrointestinal • Lower GI bleed The dispositions (outcomes) of the patients involved thus far in the calls to the Rapid Response Team are depicted in the graph below.

The Rapid Response Team is activated by a direct call to the 8-STAT line (7828) from both nurses and physicians. The team is immediately deployed, and the Patient Placement Center is notified. An SBAR (Situation Background Assessment Recommendation) report is received from the primary team and a plan of care is established. The Rapid Response Team stays with the patient until the appropriate care environment is available, or when the patient’s needs are met on the existing unit.

In addition to rapid response calls, the team is involved in other activities related to direct patient care. The Rapid Response Team makes rounds to every unit twice a day shortly after change of shift. The team connects with the charge nurse to identify any patients that have a potential for deterioration that are causing a heightened level of concern.

A follow up to each unit within 24 hours of the call to the Rapid Response Team is a standard part of the process. Retrospective chart reviews are performed on each call to identify triggers of deterioration and educational gaps. Educational opportunities are ongoing and include staff meetings, physician rounds, committee meetings, and small group huddles. Nursing and physician grand rounds will be provided in the

12

NEWS & VIEWS

This Rapid Response Team will continue to evolve in the months ahead. There is much to be learned about the Medical Center’s patient population and how the Rapid Response Team can best support the patient care areas to meet higher acuity demands. As we look to the further development of the Rapid Response Team, some of the areas of focus will be revising current policies and procedures, collaboration with the resuscitation team, family initiated and involvement in the rapid response process, and the inclusion of Ambulatory Services, Behavioral Health, and Pediatrics.

_______ 1

Institute for Healthcare Improvement, 2011. Deploy rapid response teams. Retrieved from http://www.ihi.org/explore/RapidResponseTeams/Pages/default.aspx.

Flexible Visitation Takes Off at UMMC

By: Kerry Sobol, RN, MBA Director, Patient Experience/Guest Services and Commitment to Excellence Over a year ago, the Patient Experience Team (PET) began work to establish a more flexible approach to visitation at the Medical Center. The topic was on our radar after being raised in communication forums, in executive/staff member’s roundtables, and through reports from security. In addition, our leaders expressed a true belief that Patient/Family Centered Care requires that we keep our hospital open to visitation – our patients need their families and loved ones to heal, to reach the positive outcomes we all desire, and in some cases, to die with dignity. It seemed that it was the perfect time to address some of the more common issues, create guidelines, and organize resources around visitation.

The PET is a multi-professional team that focuses on hospitalwide initiatives that affect patient and family satisfaction and engagement. One of our members is Katherine Mulligan, BSN, RN, SCNI in the R Adams Cowley Shock Trauma Center (STC).

Katherine shared early on that the STC had already started to adapt their visitation philosophy to a more flexible approach.

Katherine, along with Gena Stanek, MS, RN, CNS, and the STC Patient/Family Centered Care Council, began their journey to flexible visitation in the fall of 2009. In fact, they were piloting new guidelines on 5 North, a Multi-trauma Intermediate Care Unit at the time. On December 21, 2010, flexible visitation went STC wide. Katherine says, “Staff members were apprehensive of the “what-ifs” because we are so used to functioning in an unpredictable environment. The fact is, there are still challenging situations with patients and visitors. Are there any less? Who knows, but generally there are not more. The great thing about it is that there are clear-set guidelines now that staff members know it is supported by management and leadership, so we are generally more prepared to address issues.”

Katherine reports that visitation continues to go well for the trauma units, and in September and October of 2011, the group solicited staff member’s feedback. Some of the feedback included: “Allowing someone at the bedside 24/7 is helpful and I think families appreciate being able to listen to rounds if they are present in the am” and, “since the kinks have been worked out it seems to be going well. I still think there is some hesitancy from some staff members that are not quite as comfortable with families.” When asked what makes flexible visitation successful, people stressed consistency of setting clear expectations and patient/family education, as well as remaining open minded and understanding that the designated support person is not a visitor, but part of the care team.

Taking into account the trauma staff member’s experiences, knowledge and feedback they provided, the Patient Experience Team decided a comprehensive approach to visitation would best serve both staff members and our patients and families. The visitor policy was revised, renamed the Family Presence/Visitation Policy (EOC-019), and written to include important language from the Joint Commission and CMS (Centers for Medicare and Medicaid Services).The revision included changes to our Visitor Code of Conduct (EOC-019A). The team began to develop situ-

ational guidelines to help bring consistency to how we engage visitors and how staff members manage the many complex issues that arise. Over the course of about a year, the team developed the Visitation and Patient Experience Guidelines manual. This manual was introduced house wide, and is now on every unit and on the intranet. PET members worked with individuals during our roll-out and with units and departments across the Medical Center.

One department that took this challenge seriously was General Pediatrics. Not long after the team launched the manual, I was asked to talk to several nurses from the unit. They were in their initial stages of work and wanted to ask a few questions. As luck would have it, just as I was starting to write this article, I got an email from Erinn Davis, MS, RN, CPN, Clinical Practice & Education Specialist for the department, asking if I could review their newly developed guidelines. This was perfect timing!

I asked Erinn to describe the unit’s initial reaction to flexible visitation, and she answered, “Our initial reaction was that having an open policy would make it difficult for the nursing staff members to do their jobs. After looking at the policies of other institutions in our area, as well as around the country, reviewing the literature, and careful consideration, our eyes slowly started to open up.” In addition, she said that the first attempt at revising their stance on visitation was seen by the multi-disciplinary Acute Care Pediatric Council as not being geared towards the best interests of patients and families. So, they went back to the drawing board. Erinn says that their 2nd draft was written with their patients and families in mind. “We kept it positive and wanted to stress that our goal is to maintain a safe and calm environment for our patients.”

One of the more compelling statements Erinn made was how their families are feeling about visitation. “Families have told us that they don’t have the resources to help them when one child is hospitalized. They don’t want to have to choose between spending time with a sick child and a healthy child. They want the option of bringing their healthy children in to see their siblings.”

The team knows it will face some challenges as it moves toward implementation. Erinn added that “We expect that we are going to have to look at each scenario as it comes. We need to work together with security to ensure that our patients are safe and that we as a team are respecting the rights of our patients and their families. Our goal is to provide high-quality care in a safe and calm environment for our patients.”

The PET knew that driving flexible visitation strategies into all levels of care and departments would be challenging. The group understood this philosophy could be especially challenging in some of our critical care units. In a follow up to this article, I asked Brigid Blaber, MS, RN, Nurse Manager, NeuroCare ICU, and Cindy Rew, BSN, RN, Nurse Manager, Surgical ICU, to fill me in on how things were going on their units.

Brigid responded, “The unit staff members were split about 50/50 on the subject of flexible visitation -- some had concerns about To continue, see Flexible Visitation on page 16

WINTER 2012

13

New Guidelines Developed For Patients Independently Leaving Units By: Anne E. Naunton, MS, RN-BC, Professional Development Coordinator, Clinical Practice and Professional Development Background UMMC inpatients leaving nursing units independently for non-medical purposes has been a source of employee and patient dissatisfaction related to infection control and safety concerns. This was validated in feedback from nursing governance councils, UMMC leadership rounds, and the C2X employee forums.

In a survey done by members of the Staff Nurse Council, a total of 432 incidents of patients leaving their units were recorded throughout the Medical Center over a two-week period. A total of 172 patients accounted for these 432 incidents. This indicates that many of the patients who leave their units do so more than once during a hospital stay. The three units with the highest percentage were: N8W and N9W in the Greenebaum Cancer Center (30%); N13E/W Medicine (18%); and 11E Medicine (11%). In addition, patients were most likely to leave their rooms on Mondays and Tuesdays, and least likely to do so on Saturday and Sunday. In the majority of cases, the time frame of patients leaving units was between 7 a.m. and 11 p.m.

The reported reasons why patients leave their units are varied. The graph below highlights the major causes -- smoking (32%), walking (28%), get fresh air (15%), food (9%), and gift shop (3%). Other reasons (11%) included the need for a change of scenery and taking prescriptions to the UMMC outpatient pharmacy.

The guidelines were developed through the collective expert knowledge and experience of the multidisciplinary team members. The guidelines were approved by the Performance Improvement Steering Committee (PISC) and the Medical Executive Council (MEC) in January, 2012. The new guidelines will be implemented on April 1, 2012.

Key Points in the Patients Leaving Units Guidelines 1. The guidelines do not apply to patients on Psychiatry units.

2. The guidelines apply to competent patients with an out-of-bed order. This order is required. The use of a sitter does not supersede this requirement.

3. Nursing will be proactive in educating patients on admission regarding the importance of staying on the unit or in their room.

Nurses should document this education in the patient’s medical record.

4. We want our patients to stay in a safe environment where care and treatment is provided in a timely fashion.

5. Patients in isolation should stay in their rooms. Patients in Airborne Isolation cannot leave their rooms except for diagnostic or therapeutic reasons.

6. LIPs should not write an order that states, “Patient may leave unit unaccompanied.”

7. Nursing staff should not be asked to accompany a patient off the unit or outside the hospital.

8. There may be times when leaving the unit is encouraged for a patient as a diversionary activity, but this will be at the discretion of the assigned nurse and based on the plan of care.

As a direct result of this feedback and the data from the prevalence survey, a multidisciplinary team was formed to address the situation. The primary charge for this team was to develop guidelines for patients leaving units for non-medical purposes. The Executive Sponsor was Lisa Rowen, DNSc, RN, FAAN, Sr. VP of Patient Care Services and Chief Nursing Officer. The Team Leader was Anne Naunton, MS, RN-BC, Professional Development Coordinator, CPPD, in partnership with Kerry Sobol, RN, MBA, Director, Patient Experience, Guest Services, and Commitment to Excellence, and Susan Durbin Kinter, BSN, RN, JD, CPHRM, Vice President, Claims Litigation and Risk Management. Team members represented various patient care areas and departments throughout the Medical Center.

A review of the literature yielded little or no evidence on this topic, despite an exhaustive search of key words and databases. Policies and guidelines were received from Magnet and University Healthcare Consortium hospitals that served as a resource in developing the Medical Center guidelines.

14

NEWS & VIEWS

9. Security will not allow patients to leave the hospital with UMMC equipment. This includes, but is not limited to, IV pumps, PCA pumps, oxygen tanks, chest tubes, etc. This means that nurses should not send patients outside with our equipment. Please discuss with nursing staff so there is consistency in approach.

10. Patients who refuse to comply with the guidelines must sign an accountability form. Parents/guardian will sign for patients less than 18 years old. This is a one-time form per admission that will be placed in the patient’s paper medical record.

11. A tracking form will be utilized for patients who elect to leave the units despite education. This will allow nursing to monitor a patient’s time off the unit.

12. Any patient who fails to return to the unit within 60 minutes will be presumed to have eloped or left against medical advice.

The nurse manager or designee and the licensed care provider should be notified for a decision on appropriate placement if the patient re-enters the unit within four hours of departure. After four hours, UMMC hospital policies #COC 004 Elopement of Patients and #PROE 004/#PROE 005 Release of Patients Against Medical Advice should be followed.

To continue, see New Guidelines on page 15

Interprofessional Civility in Healthcare: Awareness, Impact & Outcomes TRENDS IN NURSING PRACTICE CONFERENCE May 1, 2012 Register online starting March 12th @ www.trends2012.eventbrite.com For more information, please contact professionaldevelopment@umm.edu New Guidelines from page 14 Location of Key Information and Unit Forms The guidelines and supporting documents will be placed in the following locations by the implementation date: • UMM Intranet Main Page - Hospital Policies and Procedures Policy PROE #001 – Patient Rights and Organizational Code of Ethical Behavior Attachment A - Patients Leaving Units Guidelines Attachment B - Unit Tracking Form Attachment C - Acceptance of Responsibility Form • Powerchart Depart Process – Patient/Family Education – Custom Information for Patients Regarding Leaving Units • Patient Handbook – Information for Patients Regarding Leaving

Units • FormFast Documents Acknowledgement of Accountability Form Unit Tracking Form Next Steps The communication and education about the Patients Leaving Units Guidelines has commenced with all Nursing and PCS governance council members, Directors of Nursing, Nurse Managers, UMMC leadership, staff meetings, and internal publications. A process to evaluate these guidelines post implementation has been developed, and the feedback will be incorporated into future revisions. Please contact Anne Naunton via email anaunton@umm.edu if you have questions or comments. .

WINTER 2012

15

Flexible Visitation from page 13 confidentiality, their ability to get their work done, over-stimulation of patients, and other anxieties. Others felt pretty strongly that it was the right thing to do, and that it wouldn’t make a big difference on how they managed their patients and families.”

Brigid worked with her staff members to discuss concerns about what could happen, and to develop strategies that would help the unit move forward. In order to overcome barriers to this project, Brigid’s team did a lot of education and coaching, and had one of their new graduate nurse cohorts do their EBP project on open visitation in the ICU. The cohort group members (all in the Clinical Nurse I position) were Jenna Lashely, BSN, RN; Mary (Maggie) Ryan, BSN, RN; Hannah Bauer, RN; Sarah Meehan, BSN, RN; Alexis Becker, BSN, RN; and Samantha Stone, BSN, RN. They read articles, conducted surveys, and held lots huddles with staff members to talk about how it was going. Brigid wanted to involve everyone in this effort, and sent support staff members to “Act With Heart” training to help give them the front-line skills they needed to appropriately communicate with patients and families.

Brigid and her team officially implemented their new strategies on July 1, 2011. She said, “We have been able to accommodate our visitors and the Designated Support Person (DSP). The staff members have done a great job and it seems to get easier and easier. The staff members have become more and more flexible when working with family members. They feel that the patient satisfaction with this process is a hundred times better and that it helps to meet their need to be with their loved one. They still have challenging family members at times, but their reaction/responses to them are so much better now and they are able to work things out. For the most part they say that 99% of families are cooperative and work with them in getting the work done.”

The Surgical ICU (SICU) had already begun to tackle a more open visitation policy under Cindy’s predecessor, Greg Raymond, MS, RN, MBA, so she felt that having “our families in the unit more frequently was already a part of our culture.” She felt the understanding of the DSP role was the most challenging aspect for the SICU. Because the unit had already embraced the philosophy of flexible visitation, identifying the DSP was not something built into their processes. They found that family at the bedside changes frequently in their unit, and that they do their best to “involve our patient’s families and support individuals in the patient’s care in any way they can.” Cindy and her staff members commented that “in the ICU, emergencies and procedures can make it difficult at times to have families at the bedside. We work hard to ensure appropriate communication with the patient and family so that they understand why they need to step out of the room, whether it be for privacy of the patient, infection control, or safety reasons.”

The PET hopes that as units and departments explore ways to provide an environment that serves their patients and families with excellence, they will use these examples as energy to keep moving forward. If we use similar language to educate our patients and families, and if we work together as a collective team, we can maintain a safe and effective care environment. We all know that our patients need their families and friends to heal, and using these guidelines to foster a proactive approach to visitation will lead to a better understanding of our visitors and their part in our patients’ experiences If you would like further information, please email Kerry Sobol at ksobol@umm.edu.

Certification Corner Getting Certified: A Nurse-Friendly Process By: Mary Lou Briggs, MA, RN-BC, Clinical Nurse II, Child Psychiatry As a “mature” nurse who recently passed a certification exam, I found myself comparing this certification preparation process to one I experienced when I first became a Certified Critical Care Nurse more than 25 years ago. At that time, depending where you worked, the certification process could involve some serious leg work. Off-site review courses, test centers in far-away places and large out-of-pocket expenses were common. It was still worth the effort. I believe being certified has made me better able to stay current with the knowledge and skills required to provide quality patient care.

When I began working full time in Child Psychiatry two and a half years ago, I had a goal of becoming a certified Psychiatric/Mental Health Nurse. After all those years, I admit to feeling slightly anxious, not knowing if my brain cells were up to testing again. I knew I had to pursue my goal.

First, I visited the American Nurses Credentialing Center (ANCC) website: www.nursecredentialing.org. I immediately felt that I had entered a very supportive environment that had everything I needed

16

NEWS & VIEWS

to achieve my goal. I found the resource manual for my specialty and an online narrated review course that was very helpful. I was able to review the study modules over a three-month period. When I felt prepared, I filled out the application, and scheduled a test date at a site within 16 minutes driving distance from my home. I was able to accomplish every step in my exam preparation from one website in the comfort of my home.

On test day, I received my results before leaving the test site. I passed the certification exam and felt wonderful about the accomplishment.

The experience this time around was a very nurse- friendly process.

In addition, I received financial reimbursement from UMMC for the expenses involved in getting certified.

If you are thinking about certification, visit the ANCC website, find out the eligibility criteria for your specialty, review the study resources that are provided and ask other certified nurses about their experience. The entire process will ensure preparation that is individualized, easy to navigate and professionally rewarding.

Honorable Mention ANCC Standard Setting Studies – Making an Impact on Your Specialty By: Dennis Brumbles, BSN, RN-BC, SCN II, Department of Behavioral Health Most nurses are familiar with the American Nurses Credentialing Center (ANCC). The ANCC is a subsidiary of the American Nurses Association (ANA) and is recognized as the premier credentialing organization for both individuals and organizations throughout the nursing profession. It awards certifications to nurses in specialty practice areas, healthcare organizations through its Magnet Recognition Program and Pathway to Excellence Program, as well as accrediting providers of continuing education programs.

My initial thought was, “Even if I do apply, what’s the chance of me being chosen?” I considered my 26 years of psychiatric nursing experience and submitted my CV with an application. I learned a few weeks later that I had been chosen for the panel. After signing the required confidentiality agreement and conflict-of-interest forms, I learned that the panel consisted of 10 psychiatric nurses from across the country that would convene to examine the certification exam and set the passing grade.

UMMC encourages all nurses to strive for ANCC certification.

There are many benefits to ANCC certification; it enhances your professionalism, recognizes you as an expert in your specialty and can be beneficial in your career path. However, many nurses do not realize that there are other opportunities that exist for certified nurses. The ANCC offers certified content expert opportunities for those who wish to further advance their specialty by volunteering in one or more of three areas: (1) content expert panels (CEP); (2) item writers; and (3) standard setting panels.

The group met in Silver Spring, MD, on Jan. 30, 2012 for a twoday review of the examination. After introductions, we provided brief information about our professional and personal backgrounds.

The panelists were chosen by geographic location, psychiatric specialties roles, and experience.

The CEP members provide ongoing review and development of the specialty test content outline for examinations. Item writers contribute questions and answers that eventually appear on the certification exams. Standard setting study panels meet for two days at ANCC headquarters in Washington D.C. During this time, they receive training for and make collective judgments about the complexity of the exam.

I received a letter from the ANCC calling for volunteers to serve as standard setting panelists to set the passing score for the revised psychiatric and mental health certification examination, which will start in April 2012. The following criteria had to be met to qualify for this panel: certified as a psychiatric and mental health nurse; valid certification until July 2012; and a minimum of three years’ certification. Additionally, the ANCC was seeking nurses with no more than five years of certification.

Lisa Rowen, DNSc, RN, FAAN, Senior Vice President of Patient Care Services and Chief Nursing Officer at UMMC, has been appointed Clinical Associate Professor of Nursing at the University of Virginia. This is in addition to three other faculty appointments that Dr. Rowen currently holds. Dr. Rowen is also an Associate Professor at the University of Maryland School of Nursing, as well as an adjunct nursing faculty member at both Johns Hopkins University and Northeastern University in Boston, MA. Congratulations to Karen Doyle, MBA, MS, RN, NEA-BC, Vice President of Nursing and Operations, R Adams Cowley Shock Trauma Center, for her election as the next president of the Society of Trauma Nurses. Karen has been on the society’s board of directors, most recently as treasurer of the organization. She takes office as president-elect at the 2012 annual conference in Savannah, Georgia, April 11-13, and will take office as president in the spring of 2013.

After setting meeting ground rules, we learned that the certification exam is revised every three years. As panelists, we began the standard setting process by taking the certification examination.

We utilized the Beuk and Angoff methods to rate our perception of the degree of difficulty and determine an appropriate passing score.

This required multiple rounds of scoring each question, analyzing averages and discussion among the panelists to reach consensus. We were able to discuss the fairness of our scores and re-score each item in each step, based on feedback from the group. In the final round, we had an opportunity to refine the process by changing the rating on a few controversial questions, following by a brief and lively discussion.

The results were programmed into a computer, and the group was informed of the cut score at the end of the second day through the use of statistical analysis. The group is prohibited from revealing the passing score, as well as the pass-fail average, due to our confidentiality agreement. This experience gave me an opportunity to network with professionals from across the country, learn about the process of how certification exams are created and increase my knowledge of psychiatric and mental health nursing.

Professional Advancement Model Congratulations to the following nurses that were promoted in January 2012 Senior Clinical Nurse I Stacey Chaney Hydorn, BSN, RN - Adult Emergency Department Audrey May Lupisan, BSN, RN, CMSRN - 13 East/West Nicole Adwell, RN, CMSRN - 13 East/West Dawn Calderone, BSN, RN, CCRN - Surgical Intensive Care Unit Penny Happel, BSN, RN - Interventional Radiology Carol Armstrong, BSN, RN, CPN, CDE - Center for Diabetes and Endocrinology Christina Fellner, MS, RN, CNL - Pediatric Intensive Care Unit Mary Arnett, RN, CMSRN - C5W Senior Clinical Nurse II Elizabeth Wingo, BSN, RN, PCCN - Multi-Trauma Intermediate Care Stacey Trotman, RN, CMSRN - 13 East/West

WINTER 2012

17

Core Measures Core Measure Set Reaches the Top Decile: Acute Myocardial Infarction Scores 100% By: Crystal Evans, BSN, RN, Senior Core Measure Coordinator, Quality and Safety Background

Team Strategy and Process Plan

The University of Maryland Medical Center has scored among the top 10% of hospitals in the Acute Myocardial Infarction (AMI) core measure set. The seven measures scored in our practice and population are: (1) aspirin at arrival; (2) aspirin prescribed at discharge; (3) ACEI (Angiotensin Converting Enzyme Inhibitor) / ARB (Angiotensin Receptor Blocker) for LVSD (Left Ventricular Systolic Dysfunction); (4) adult smoking cessation; (5) beta blocker prescribed at discharge; (6) PCI (Percutaneous Coronary Intervention) within 90 minutes of arrival; and (7) statin prescribed at discharge. Every measure met 100% compliance with the Centers for Medicare and Medicaid (CMS) and The Joint Commission (TJC) guidelines in the 3rd (July-September) and 4th (OctoberDecember) quarters of 2011.

The committee’s efforts in exploring various approaches to improve performance on the measures were constant and unwavering.

The top priority in improving the rates was ensuring the required documentation was completed. The committee’s use of several approaches accounts for the current success: • Concurrent review; • Technological solutions; • Coding validations; • Monthly review of every PCI; and • Peer review of all outliers

A Team Approach In April of 2010, the Core Measure Steering Committees were given the charge by Jonathan Gottlieb, MD, Senior VP and Chief Medical Officer, to accomplish two goals (1) to meet the MD state average in each core measure set by October 2010; and (2) to meet the top decile by January 2011. These goals posed a challenge for each of the core measure committees to accomplish.

This task required expertise in understanding the guidelines, reviewing the current practice, analyzing areas of failure, and implementing process changes that would assist in meeting the care guidelines established by TJC and CMS. The Cardiology Core Measure Committee was charged with improving the performance of the Acute Myocardial Infarction (AMI) core measure set as well as the Heart Failure core measure set. This committee is a multidisciplinary team that is familiar with the practices and needs of the cardiac population.

Cardiology Core Measure Committee Members Shawn Robinson, MD, Co-Chair Larry Stafford, MD, Co-Chair David Hunt, MSN, RN, Co-Chair Badia Faddoul, MS, RN, Facilitator Crystal Evans, BSN, RN Sharon Rochon, BS, RN & Mary Halliburton, RN, IT Valerie Strickroth, CCT Mangla Gulati, MD Karen Vojtko, MS, RN Michele Zimmer, MS, RN Jane Malone, BSN, RN Kim Reck, MS, CRNP Deborah Nolan-Reilly, MS, RN Jo-Ann Sikora, MS, CRNP Kathryn Novello Silva, MD

18

NEWS & VIEWS

Collaboration and Technological Integration Concurrent review identifies opportunities for improvement while the patient is in the hospital. This approach allows for documentation to be added while treatment is being rendered.

Cases are identified by the admit order and those cases with a diagnosis of AMI are reviewed daily. Any cases missing the required documentation are referred to Lisa Hartin, BSN, RN, and Jane Malone, BSN, RN, Cardiology Patient Care Coordinators.

These coordinators contact the resident responsible and ensure documentation is complete. For clinical areas outside of Cardiology, the residents are notified by the Senior Core Measure Coordinator.

Technological solutions provide a systematic approach for triggering the providers to complete the required documentation on discharge. The depart process in Power Chart gives the providers (1) the opportunity to identify core measure cases; and (2) a structured approach to completing required documentation. Once the case is identified as an AMI, each measure requiring specific documentation at discharge must be answered in order to complete the depart process. The usefulness of this approach is evident in the perfect result captured for the newest AMI measure, “Statin prescribed at discharge,” which began January 2011. Many thanks to the IT department for the development of this tool and the continued revisions required to maintain compliance with TJC/ CMS guideline changes.

Coding validation is explored to ensure the correct cases are included in the measure set population. This population is identified by specific ICD-9 discharge diagnosis codes. A working relationship with the coding staff has proven essential in establishing the accuracy of the AMI measure population. Many thanks to the coding department for their patience and assistance.

The STEMI Task Force Committee continues the work of identifying opportunities for improving PCI timing and works with all necessary disciplines in house and within the community To continue, see Core Measures on page 19

We Discover Journal Club Hot Topics By: Patricia Woltz, MS, RN, Research Nurse, Nursing and Patient Care Services The January meeting of the Journal Club was hosted by Nicole Adwell, RN, CMSRN, Clinical Nurse II, and Stacey Trotman, RN, CMSRN, Senior Clinical Nurse II, both from13 East and West.

With standing room only, Nicole and Stacey skillfully facilitated a review of a quasi-experimental study that examined nurses rounding hourly or every two hours and the effect those rounds had on patient call light use (frequency and reasons for use), patient satisfaction, and falls. The study, which involved 27 units in 14 hospitals, found that four weeks of diligent hourly rounding significantly improved all outcomes (Meade et al., 2006). The discussion that followed focused on the implications of the evidence for hourly rounds related to UMMC practice, education, and quality improvement.

Discussion: • Hourly rounds can mean different things to different people and not all understand it. Communicating with patients and families, beginning at admission and via public bulletin boards or posting a rounding log in patient rooms, helps to promote patient and family understanding, provides reassurance, and holds staff accountable.

• Different patient care providers can effectively participate in hourly rounding. Many units have found that sharing responsibility between nurses and PCTs constitutes best practice.

• The 3, 4, or 5 “Ps” that are emphasized on a given unit may vary based on a unit’s assessment of its patients’ anticipated needs.

• Patient care areas aware of their monthly patient satisfaction scores have used the data to look for trends and, when appropriate, implemented Plan-Do-Check-Act cycles. With changes in scores, staff have collected two weeks of call light use data, then developed and implemented targeted interventions -- a great example of data driving practice.

• Hourly rounding at UMMC arose out of the shared governance structure. Clinicians at UMMC researched how they could improve performance with nursing-sensitive quality indicators in the areas of safety and patient satisfaction. They found evidence to support the practice of hourly rounds.

• While this study provided strong evidence for hourly rounding, sustainability was not evaluated. Getting buy-in from staff is important to continued success.

Article Reference: Meade, C., Bursell, A., Ketelsen, L. (2006). Changing Effects of Nursing Rounds on Patients’ Call Light Use, Satisfaction, and Safety: Scheduling regular nursing rounds to deal with patients’ more mundane and common problems can return the call light to its rightful status as a lifeline. AJN, 106(9), 58-70.

Contact Stephanie Hague by email shague@umm.edu if you would like a copy of the article.

Core Measures from page 18 to improve the patient flow of door to balloon time. During its monthly meeting, all PCI cases are presented and reviewed. This committee is multidisciplinary whose continuous focus has made a huge difference in improving PCI timing and patient outcomes.

Evaluation and Re-Education The cases that fail any measure are compiled into an outlier report that is sent monthly for case review by Drs. Shawn Robinson, Kathryn Novella Silva, and Mangla Gulati. This report is a list of each measure failure, which includes patient name, attending physician, and resident physician caring for the patient, and the reason for the failure. This review has assisted in identifying patterns and is useful in educating staff regarding measure definitions and documentation requirements.

Outcomes The combination of these efforts led to the initial achievement of reaching the top decile for the AMI measure set in January and February of 2011. All measures for both months were at 100%.

There was one outlier in March that prevented the success of reaching the top decile for the first quarter of 2011. Although great success has been achieved, continued effort is needed to maintain this gain. Hospitals nationwide are on this journey to reaching the top decile. For the University of Maryland Medical Center, this continued effort yields a place for us among the top performers.

Congratulations UMMC – our commitment to excellence has earned us the score of 100% on every measure of the AMI core measure set for six consecutive months from July through December 2011.

The leaders of the Cardiology Committee continue their active role in developing solutions to any challenges identified for maintaining the top decile performance of the AMI core measures. These challenges, as well as the success of solutions implemented, are communicated to various management forums.

WINTER 2012

19

University of Maryland Medical Center 22 South Greene Street Baltimore, MD 21201 www.umm.edu

Clinical Practice Update DO NOT CRUSH Hazardous Medications • Pharmaceuticals are potentially hazardous to those who handle the medications and to the environment when disposed of improperly.

• The purpose of Special Handling Precautions is to protect employees and the environment from the hazards presented by the use, handling and disposal of hazardous medications.

• Wear appropriate Personal Protective Gear (PPE).

Important Points to Remember:

Hazardous medications are identified with **Haz Waste** on the label.

• Do not crush the medication!

• Read the instructions on the label or eMAR to determine if the product can be dissolved.

• Contact the pharmacy if a liquid is needed.

• In case of leak or spill of hazardous medication: – Isolate and mark the area – Don proper PPE – Use designated spill kits to clean – Call Safety Department at 8-8711

for large spills (>10 ml) or when

in need of assistance.

• When caring for a patient receiving hazardous medications, their bodily fluids are potentially hazardous as well.

• Protect yourself ➠ Wear your PPE!

Hazardous Drug Disposal

Disposal instructions are on the label and/or on the eMAR. * P-Listed ➠ Black Bucket (including package) * All other hazardous pharmaceuticals: If not empty ➠ Black Bucket If empty ➠ Red Bag

NO medications are to be disposed of down a drain.

For questions about information contained in this update, contact Denise Choiniere at dchoiniere@umm.edu or # 8-2009.