news views Summer 2012
A Publication of the Department of Nursing and Patient Care Services
University of Maryland Medical Center
Hourly Caring Rounds – Every Hour…Every Day…Every Patient Kerry Sobol, MBA, RN, Director, Patient Experience and Commitment to Excellence
Have you heard the buzz? Hourly caring rounds are coming to a patient care area near you! Over the last eight months, UMMC has been preparing to launch hourly caring rounds in patient care areas across the organization. to life for our patients and families. Along the way, Sobol and the Hourly caring rounding, also known as purposeful rounding, is a team presented to several councils and groups to get feedback, tactic used by patient care staff across the nation to improve patient ideas, and commitment to the concept. These groups included the safety and patient satisfaction. Purposeful rounding is defined as an Clinical Practice Council, the Magnet Champion Group, the Staff Nurse evidence-based, proactive strategy used by patient care teams to Council, and the nursing directors and manager groups. engage their patients and families. Lisa Rowen, DNSc, RN, FAAN, The team settled on two models that are prominent in the Senior Vice President of Patient Care Services and Chief Nursing literature as being effective. They include the “4 Ps” Officer, states, “The goals of hourly caring rounds are (Pain, Positioning, Personal needs, and Possessions) to reinforce our concern for and carry out activities model for inpatient care, and recommended the to ensure the patient’s safety, comfort, and proper use of the “PPD” (Pain, Plan of care, and Delays) positioning; assess, provide, and evaluate effective pain model for ambulatory, outpatient, and ED settings. A control; assess and implement necessary toileting or signature look and feel for rounding was developed elimination activities; and ensure the patient’s desired with the expert help of Michelle Bamburack, possessions – and the call light – are within reach.” Manager of Communications and Digital Signage. A team of nurses representing the major The group developed a patient/family education nursing councils and varying departments, led by brochure that will be easily adopted by all areas. In Kerry Sobol, MBA, RN, Director of Patient Experience addition, the team developed signage that will be and Commitment to Excellence, were on a mission to located in every patient care area and will serve as take hourly caring rounds to a new level at UMMC. In a documentation tool. addition, a group of nurse managers acted as content In July, the team was prepared to educate our and process advisors as the team completed their managers and staff on the plan for launching hourly work and made decisions. How could we make this caring rounds. The team developed education plans tactic our own and fit it into our culture of caring? for managers, clinical leaders, and staff of all patient The team went to work in March 2012 to develop an Your Safety is Our Priority care areas to learn and understand the connection inclusive plan that will bring hourly caring rounds UNIVERSITY of MARYLAND MEDICAL CENTER
Hourly
Caring Rounds
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Lisa Rowen’s Rounds: Transitions This past month, I had a moment of extreme joy: My daughter Emily started her first job as a new graduate nurse. Ever since Emily’s decision to become a nurse, I have vicariously lived her journey: selecting, applying, and being accepted to her nursing school of choice; studying for and moving through rigorous courses and clinical practicum experiences; successfully passing the nursing board exam; interviewing for and being offered a nursing position in an ICU of a large academic medical center in another state; moving to a new city; and beginning orientation. As a nurse colleague, I want Emily and all new nurses to have a meaningful onboarding experience in which they feel safe to learn new skills, are challenged to think critically, and become integrated as valued, contributing members of the team. Nurses who graduated prior to 1994, as I did, were issued a provisional nursing license that restricted some of the functions and tasks we could perform when we started working. I remember working as a graduate nurse but Lisa Rowen, DNSc, RN, FAAN not being allowed to administer medications prior to getting my license. This bought me a couple of months to focus Senior Vice President and on nursing basics, time management, and performing clinical tasks without the additional challenge of medication Chief Nursing Officer, Nursing administration. In addition, the surgical patients I cared for had average lengths of stay much longer than those of and Patient Care Services continued on page 7.
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Summer 2012
In This Issue 1
Hourly Caring Rounds
1
Lisa Rowen’s Rounds: Transitions
2
Corporate Compliance
3
Nursing Role in Health Care Reform
4
Guidelines Implemented for Patients Independently Leaving Units
6
Ann Regier Retires
6
C5 East Celebrates Zero Falls
8
AU Meds
8
New UMMC Shuttle Service
9
Certification Corner
10 Medical Orders for MOLST 11 Core Measures 15 STC Infection Reduction Collaborative in India 16 Honorable Mention 18 Student Nurse Residents Present Poster Summit 19 We Discover 20 Clinical Practice Update
Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer and Toya Jackson, UMMC Compliance Manager
Starting with this issue, the Medical Center Compliance Program will provide a short “Frequently Asked Question” (FAQ) section in each issue of News and 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 provide any topic suggestions by emailing compliance@umm.edu or tjackson2@umm.edu. Compliance Frequently Asked Question Q: When is a medical record not a complete medical record? A: When part of the original paper portion inadvertently leaves the Medical Center. Everyone understands the importance of having a complete and accurate medical record. This is important not only during the patient stay and for continued treatment, but also for coding, billing,
quality reviews, surveys, etc., all of which occur after the patient is discharged. Here is an example where a chart inadvertently leaves the Medical Center: The unit secretary calls out sick for the Wednesday night shift on Unit X. Patient John Doe on Unit X expires on Wednesday at 9:50 pm. Because he was a crime victim, the expired patient must be sent to the State Medical Examiner’s office. When the transportation personnel arrive on Unit X, the charge nurse on duty grabs the chart and puts it with the patient. On Thursday at 8:00 AM, an employee from HIM arrives on Unit X and requests John Doe’s medical record. The day shift unit secretary indicates it is not on the unit. Per Policy MOI-004, the unit secretary notifies the nurse manager who, after several conversations and calls, is able to locate the chart, which then must be retrieved from the Medical Examiner’s office. If information from the medical record needs to leave the hospital, only a copy of pertinent information should be sent. Expired patient records shall remain on the unit after discharge, with the one exception of a pending autopsy request that will be performed at the Medical Center Pathology Department. For additional guidance, please reference UMMC Policy MOI-004 & MOI-004A.
Find News&Views online at http://www.umm.edu/nursing/newsletter.htm and on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm
Editor
Anne E. Naunton, MS, RN-BC 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 Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Suzanne Leiter Executive Assistant to the Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services Susan S. Carey, MS Professional Development Coordinator Clinical Practice and Professional Development Angela Sintes Tyrrell, MS, RN, CNL Clinical Education Specialist Clinical Practice and Professional Development
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 practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines
Send completed articles via e-mail to anaunton@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 2012 Winter 2013 Spring 2013 Summer 2013
Due Date October 1, 2012 January 7, 2013 April 1, 2013 May 22, 3013
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 The Nursing Role In Health care Reform M. Susanne Anderson, MS, RN, ACNP-BC, Professional Development Coordinator, CPPD
The world of health care is changing and becoming more challenging than ever. The federal government hopes to provide health care for an estimated 32 million uninsured Americans via the Affordable Care Act (ACA). At the same time, the government is looking to cut health care costs. Experts tout that our current system of Medicare and Medicaid is not sustainable and changes in payment structures are forthcoming. Providers will be asked to measure and report the quality, safety, and efficiency of care provided and reimbursement will be tied to these measures. Locally, the state of Maryland plans to reduce the Health Services Cost Review Commission reimbursement rate to hospitals, regardless of the rate of inflation or other financial challenges. In short, we are going to be asked to do more with less. What does this mean for the nursing profession? The ACA is designed to change our current health care system from one that focuses on providing care for illness to one that provides patient-centered preventative care. Nurses will be instrumental in not only providing care that will improve patient outcomes during times of illness, but also in guiding patients in their efforts to maintain wellness. Through health promotion, system-wide cost savings can be realized with the reduction of chronic disease. Nursing must participate in changing the way health care is delivered to patients both in hospitals and in the community. The 2010 Institute of Medicine report, “The Future of Nursing: Leading Change, Advancing Health,” examined how nurses can play a vital role in achieving the goals of health care reform. The committee developed four key messages: ◗◗ Nurses should practice to the full extent of their education and training. ◗◗ Nurses should achieve higher levels of education through an improved education system. ◗◗ Nurses should be full partners with physicians and other health care professionals in redesigning health care. ◗◗ A need exists for better data collection and information. Back in her time, Florence Nightingale recognized the importance of collecting and recording patient information, and the impact it had on the way care was provided. Documentation and data collection is still a significant part of the role of nurses. Information management is changing and has evolved into a new role for nursing, the role of nursing informatics. Nursing informatics is the sub-discipline of health informatics that, as defined by the American Nurses Association (ANA), is a specialty that integrates the sciences of nursing, computer, and information to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings.1 It allows the improvement in accessing patient information at the point of care, and enhances nursing abilities to benchmark, monitor, and audit quality measures.2 In 2007, the Maryland Nursing Workforce Commission examined the ongoing nursing shortage and focused on ways to decrease or eliminate work life dissatisfiers for nurses. Nursing documentation was identified as one such dissatisfier. Nurses routinely spend 15 – 25% of their time documenting patient data and care. Many felt that the documentation was redundant or unnecessary and that it takes away from the ability to administer direct patient care.3 The “Rights” don’t just belong to medication administration anymore. The challenge is not to collect more data, but rather to collect the right data and to turn it into something meaningful. The right
information must be available to the right person, at the right time, to allow that person to make the right choice. Nurses are very inquisitive and intuitive. Documentation must encompass more than just a series of data points; it must add value to our practice. The challenge is to look at data in a different way and make them more meaningful to the bedside clinician. Additionally, we need to refine our documentation to “tell the patient’s story,” and highlight those elements that are important to the patient and not just capture the medical plan. Nursing is recognized year after year as being the most trustworthy occupation in the workforce, in part because of the holistic care provided to patients. Ironically, much of what nurses do best, offering reassurance, advocating for the patient, supporting families and friends, guiding and educating patients, is not readily evident in the documentation. Patients are savvier today about finding health care information and have more choices about where to obtain their health care. Many patients enter the hospital armed with information, and misinformation, about their ailments. They have high expectations about the knowledge, skills, and ability of nurses to provide excellent health care. Many patients are embracing technology and use applications on their computers and smartphones to better manage their own health. Patient’s involvement in their own wellness and health promoting behaviors is essential, and nurses can play a vital role as health coaches. Nurses can share information with the patients during coaching sessions to reinforce the cause and effects of their choices. The application of knowledge at a time when it is meaningful to the patient will impact their outcomes. Keeping patients at home after their discharge has significant financial impacts, as well as promoting patient wellness. Telehealth and remote home care monitoring devices will be called upon to a greater extent in the future to help bridge the gap of provider shortages. Personal technology can also be applied at the bedside with a multitude of applications available today to support clinical decision making and to get the latest news and updates on studies and advancements in health care. It is essential that as nurses, we maintain the skills to keep up with the changes in technology and the evolving health care environment. Not only must we possess skills to navigate the electronic medical record and enter or extract vital information, but we must know how to use technology to research the latest practice information and assist families in their pursuit of valuable knowledge. References 1 American Nurses Association. (2008). Nursing Informatics: Scope & Standards of Practice. Nursing Books.org: Silver Springs Maryland. 2 A Report of the Maryland Nursing Workforce Commission, Documentation Work Group (2007) Challenges and Opportunities In Documentation of the Nursing Care of Patients. 3 Saba, V. and McCormick, K. (2011). Essentials of Nursing Informatics (5th ed). McGraw Hill Medical: New York.
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Guidelines Implemented For Patients Independently Leaving Units Anne E. Naunton, MS, RN-BC, Professional Development Coordinator, CPPD Cescelle Barbour MS, RN, PCCN, UMSON Graduate Student
UMMC inpatients leaving nursing units independently for non-medical purposes have been a source of employee and patient dissatisfaction related to infection control and safety concerns. This was validated through feedback from Nursing and Patient Care Services Councils, UMMC leadership rounds, and the C2X employee forums. In a prevalence survey done by members of the Staff Nurse Council, a total of 432 incidents of patients leaving their units (PLU) were recorded throughout the Medical Center over a two week period. There were 172 patients that accounted for these 432 incidents. This indicates that of the patients who leave their units, many do so more than once during a hospital stay. 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 members of the team represented various patient care areas and departments throughout the Medical Center. The guidelines were completed as a direct result of the collective expert knowledge and experience of the multidisciplinary team members. The guidelines were approved by the Performance Improvement Steering Committee and the Medical Executive Council, and they were implemented on April 1, 2012. There were two methods utilized to evaluate the effectiveness of these guidelines. In the first method, nurses completed a tracking tool on three units that represented different types of patient populations. The second method involved semi-structured interviews with the nursing staff. Nurses were questioned about topics such as: guideline content and dissemination; educational preparation; barriers; facilitators; and suggestions for improvement.
The PLU rates of three hospital units were compared before and after the guidelines’ implementation. Overall, the average PLU rate was reduced by 68.25% after implementation. Specific reductions were noted on three units: 13 E/W by 90.79%; General Pediatrics by 25%; and Weinberg 5 by 42.31% (Figure 2). Figure 2
A high number of PLU incidents were shown to occur during Mondays, Tuesdays, and Wednesdays. Of the 40 PLU incidents, most of the incidents were reported to occur from 7:00 a.m. to 2:59 p.m., and the time that patients were off the units ranged from 14 minutes to one hour (Figure 3). Figure 3
Quantitative Results During the PLU tracking date of June 24 to July 7, 2012, a total of 40 incidents of patients leaving the unit were recorded by 3 hospital units. There were 23 patients that accounted for these 40 incidents. Again, this indicates that of the patients who leave their units, many do so more than once during a hospital stay. A breakdown of incidents and the percentage distribution per hospital unit are shown in Figure 1. Figure 1
The reasons why patients leave their units pre and post guideline implementation are relatively the same. The top four reasons why patients leave their units include: ◗◗ ◗◗ ◗◗ ◗◗
take a walk; get fresh air; get food; and go to the gift shop.
news &views
For those patients who left their units, 98% were given some type of PLU education. Verbal education was the most common type of PLU education given (83%), while 17% of patients received both verbal and written education (Figures 4a and 4b). Upon leaving the unit, 72% of PLU incidents had signed accountability forms and 28% did not have signed accountability forms. A signed accountability form by the patient is a requirement of the new guidelines. Figure 4a
Figure 4b
Qualitative Results Generally, nurses felt that they received ample education to prepare for the PLU guidelines roll out. Nurse managers and senior clinical nurses were instrumental in ensuring that staff members were informed about the implementation of the guidelines and the content. The PLU guidelines were characterized by the nurses as a good body of information that helped them make high quality decisions when faced with the circumstance of patients wanting to leave their units. The guidelines address patient safety issues, hospital responsibility, and patient rights, while also informing patients of their accountability. The PLU guidelines have two major components that include patient educational tools and a patient accountability form. The educational component consists of proactively educating patients at risk for leaving the unit through verbal and written information. Patient educational materials are available in the form of a patient handbook and patient handouts. The second component involves the use of an accountability form. It was reported that education helped some patients understand the benefits of the guideline, thus making them think twice before leaving the unit. The accountability form, which thoroughly spells out the risks of leaving the unit, helped clarify the rules and patient’s responsibility when leaving the unit. Conclusion The PLU guidelines are a resource for nurses and other members of the health care team to promote patient safety and employee satisfaction. There was some resistance from the patients and the nursing staff in the initial phase of implementation. However, this can be remedied by the following strategies: ◗◗ a consistent approach to managing the guidelines across all patient care areas, especially for patients on intravenous infusions or analgesic pumps; ◗◗ increasing the availability and usage of educational tools and the patient handbook; ◗◗ engaging patients and families proactively with information; ◗◗ completion of the patient accountability form; ◗◗ utilizing a team approach at the unit level by involving charge nurses, nurse managers, PCTs, unit secretaries, and LIPs early in the process; ◗◗ reinforcement of the guidelines’ content and associated positive outcomes during huddles and staff meetings; and ◗◗ reminders that patients who attempt to leave the Medical Center attached to equipment will be stopped at the door by our security partners. If you would like additional education, please contact Anne Naunton by emailing anaunton@umm.edu.
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Ann Regier Retires Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services
After 34 years of outstanding and dedicated service to the Medical Center, Ann Regier, MS, RN has retired. As the Director of Clinical Practice and Professional Development (CPPD) in the Department of Nursing and Patient Care Services (PCS), Ann’s responsibilities have been to translate individual and departmental educational needs into consistent and effective educational programs, partner with others to assess and improve specific patient care processes, and manage several grants. Prior to her current role, Ann demonstrated progressive leadership experience while in a variety of roles. The diversity of Ann’s roles and her contributions to the Medical Center are impressive. She served as a staff nurse and educator on Neurosurgical Acute Care/IMC, a nurse manager of Neurosurgical Acute Care/IMC and Pain Service, a project manager for the Technology Assimilation Project, a project director for the Productivity Enhancement Project, and a professional development coordinator.
Ann Regier, MS, RN
Under Ann’s leadership since 2001, CPPD has continuously evolved to: ◗◗ Provide education, practice, and development support at the individual, unit, and discipline level. ◗◗ Ensure integration of the work of the councils, the nursing strategic plan, and the annual operating plan for PCS with the UMMC strategic plan. ◗◗ Collaborate with the Maryland Hospital Association on numerous initiatives including: • The design and implementation of the Clinical Assignments for Health Care Students (CAHS), a system used by hospitals and schools of nursing in Maryland to optimize clinical placements. • Who Will Care? Investing in a Comprehensive Solution to the Nursing Shortage to increase – and eventually double – the number of nursing students graduating from the state’s nursing schools. ◗◗ Receive a $1.2 million Nursing Support Program I grant sponsored by the Health Services Cost Review Commission Nursing Support to support nurse retention, recruitment, and improved nurse practice environment. ◗◗ Partner with the University School of Nursing (UMSON) on the Nursing Support Program II, a program to increase the pipeline of nursing faculty in Maryland in partnership with the State of Maryland Department of Health and Mental Hygiene and the Health Services Cost Services Review Commission. ◗◗ Partner with the UMSON to increase the numbers and types of clinical placements available to students. ◗◗ Contribute substantively to attainment of Magnet Designation for the Medical Center. In her retirement, Ann plans to pursue her passion for playing tennis, spend time with her family, and travel. Ann’s knowledge, expertise, wisdom, and big heart will be missed by those of us fortunate to call her a colleague. We wish Ann the very best as she embarks upon the next phase in her life.
C5 East Celebrates Zero Falls for a Full Quarter Visitacion Casal, BSN, RN, SCN I, Gudelsky 5 East
The C5 East Medical-Surgical Progressive Care Unit recently marked a full quarter without any falls. The unit remained fall free for 91 days, from April 1 to June 30, 2012. The staff celebrated the achievement at a staff meeting with their new nurse manager, Simone Odwin-Jenkins, MBA, BSN, RN. C5 East has historically struggled with a high fall rate and performed below the benchmark. The unit initiated a falls committee to address the challenge of reducing falls. Among others, the following interventions were implemented: ◗◗ Educators developed a learning cascade kit to educate staff and address any knowledge gaps. ◗◗ A falls representative was chosen to represent the unit and attend the institutional falls committee meetings. ◗◗ All critical and high fall risk patients are placed on low-beds and bed alarms are utilized.
Daily huddle on C5 East
◗◗ Falls are discussed in daily huddles on all shifts. Critical or high-risk patients and the interventions in place are identified. The huddles serve as an avenue for the staff to discuss alternative interventions when current strategies do not work. ◗◗ Hourly rounds are conducted by all staff – RNs, PCTs, charge nurses, and unit secretaries. ◗◗ A falls tracker board was created to serve as a visual cue for the staff and has key elements related to falls, including the number of days since the last fall, post-fall root cause analysis, post-fall continued on page 7. checklist, and goals.
news &views Rounding Report continued from page 1. today’s acutely or critically ill hospital patients. While our patient assignments tended to consist of greater numbers of patients than assignments of today, we actually had patients on our unit for days before and weeks following their procedures. Our patient charts were on paper and in one place. When an important new order was written, the resident or attending typically sought us out to tell us about the order, and we frequently were able to have a brief discussion about the plan of care. Compared to many of us, new graduate nurses of today are licensed almost immediately after passing the board exam, care for significantly ill patients in an abbreviated timeframe, use computerized documentation that has reduced the human interaction between clinicians, typically work 12 hour shifts that may reduce continuity in care and understanding of that care, are responsible for many more regulatory requirements for patient care and documentation, and use sophisticated technology in the care of their patients. I can vividly remember feeling overwhelmed in my own experience as a new nurse in 1982, to the point of nausea on my drive to work for each shift. In fact, I still feel nauseated when I think back to that time. If I felt this way 30 years ago, I wondered, “How do new nurses cope with today’s stress?” I decided to review the recent literature to refresh my understanding about what new graduate nurses experience. Clearly, new graduate nurses have a stressful transition to becoming competent practitioners. Feelings of excitement at entry into practice can quickly move toward a sense of vulnerability, disappointment with reality, and dissatisfaction with their new roles. It takes at least 12 months or more for most new graduates to feel comfortable as a nurse. These reasons contributed to the Institute of Medicine recommendation to create Nurse Residency programs, to better address the onboarding and socialization processes of new graduate nurses so that their transition would improve competencies and job satisfaction. Even with nurse residency programs – and we have this type of program at the Medical Center – challenges for new grads remain alive and well. A recent descriptive study of new graduate nurses in a nurse residency program in the Northwest revealed that nurse residents feel like they have a frantic pace that verges on chaos. They note there is no “typical day” and the workload can be overwhelming. In awe of their colleagues’ ability to expertly care for multiple patients, new graduates wonder if they will be able to keep their heads above water. They also feel stress from not knowing things, whether because of being inadequately prepared by their nursing education programs; a lack of communication among the team; not having enough time for careful assessment or critical thinking; or not having a connection with their preceptors.1 In addition, in this study and others, new graduate nurses reported stress caused by the fear of making an error that would result in harm to a patient.1,2 The good news is that in this same study, the new graduates felt valued by their colleagues, the health care team and the patients. This is the type of gratifying feeling that gives people the courage to continue, even when feelings of inadequacy arise. When our individual contributions are valued and respected by colleagues, patients, and supervisors, we feel competent and confident and a unit culture is created that promotes job satisfaction, teamwork, and commitment. We all want this type of work environment, and new graduate nurses thrive on it. How about the preceptors of all of the new graduates? How are they feeling? It is a huge responsibility to precept a new nurse under
any circumstances. In areas with a high concentration of new nurses, it can be exhausting for the preceptors. Training and teaching requires vigilance from the preceptor to keep the patients and new nurse safe; explain nursing practice and care standards; provide evidence for best practice; review policies and procedural guidelines; extend unfailing care and support to the new graduate; demonstrate how to use resources to solve any problem that can come up; and describe the who, what, where, when, and how of everything that happens in our complex Medical Center. Even if a nurse loves being a preceptor, the accountability for delivering a safe and competent new graduate into practice is astounding and overwhelming. At the Medical Center, nurses selected relationship-based care (RBC) as the model for the care we provide to our patients. In RBC, we embrace the belief that the relationship between the nurse and the patient/family provides the foundation for the patient care experience. It is through this therapeutic and continuous relationship between the nurse and the patient/family that we coordinate care and achieve exceptional outcomes. We also recognize the centrality of our relationship with our interdisciplinary colleagues and the relationship with the self and how these shape and enhance the patient/family experience. What would happen if we consistently embraced RBC for how nurses care for each other and for how all members of the health care team relate to each other? Our healing environment, the level of trust between us, and our ability to meet the needs of one another would be enhanced by a focus on knowing what matters most to each of us. We would be accountable for how we welcome, respect, value, show appreciation for, and integrate every member into the team. This is what I hope for all of us, for every team member at the Medical Center, and in particular, for all of our preceptors and new graduate nurses. It is nursing’s legacy and life cycle and our promise for the future. And, of course, this is what I hope Emily will experience as she transitions to her new role as a nurse. References 1 Clark, C.M. and Springer, P.J. (2012). Nurse residents’ first-hand accounts on transition to practice. Nursing Outlook 60(4), e2-e8. 2 Ferguson, L. and Day, R. (2007). Challenges for new nurses in evidence-based practice. Journal of Nursing Management 15, 107-113.
Zero Falls, continued from page 6. ◗◗ RNs and PCTs conduct bedside shift handoffs. ◗◗ RN-to-PCT and PCT-to-PCT report includes the fall status of a patient. The nurses’ Kardex was also revised to include the fall status. ◗◗ Post-fall huddles are conducted after a fall incident in order to identify causative factors. ◗◗ A post-fall checklist was created to consistently guide the RN in the event of a patient fall. Last but not least, was the creation of a culture of safety and accountability. All staff on the unit, including charge nurses, unit secretaries, and housekeepers, take ownership of the critical or highfall risk patients, not just the assigned RN and PCT. When a bed alarm activates, all staff are expected to respond immediately. This bundled approach has allowed C5 East to keep patients safe and reach its goal of a full quarter without a fall. To date, C5 East is 103 days without a fall and gearing up for two consecutive quarters free of falls.
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AU Meds Paul Thurman, MS, RN, ACNPC, CCNS, CCRN, Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center
A medication error is defined as any discrepancy between the prescriber’s interpretable medication order and what was administered to a patient.1 Medication errors include omissions, unauthorized drug, wrong dose, extra dose, wrong route, wrong form, wrong technique, and wrong time. Medication errors occur in all stages of the medication use process, most frequently at the prescribing and administration stages. Medication error rates in hospitals are reported to occur between 2.4 – 11.1% of opportunities or scheduled doses according to the Institute of Medicine.2 Medication errors may be investigated by the following methods: ◗◗ directly observing medication administration; ◗◗ reviewing the patient chart and incident reports involving medication errors; ◗◗ attending medical rounds to listen for clues that an error has occurred; ◗◗ interviewing health care personnel to stimulate self report; ◗◗ analyzing doses returned to the pharmacy; ◗◗ testing urine for evidence of omitted drugs and unauthorized drug administration; ◗◗ examining death certificates; ◗◗ attending nursing change of shift report; and ◗◗ comparing the medication administration record (MAR) with licensed independent prescriber (LIP) orders. A study compared these methods with those of research pharmacists that confirmed 457 of 2,556 doses to be in error, producing a true error rate of 17.9%.1 Trained observers detected 300 of these errors and 73 false positives, which produced an error rate of 14.6%. For the same doses, chart review detected 17 of the 457 errors and 7 false positives, yielding an error rate of 0.9%, while incident report review detected only one error for an error rate of 0.04%.1 However, the data collectors missed 157 errors during direct observation, 440 during chart review, and 456 during incident report review.1 UMMC has acquired AU Meds, the direct observation method of detecting medication administration errors, developed by Auburn University research pharmacists. This method of observation is blinded, meaning that neither the observer nor the nurse know if an error has occurred until the observations are compared to LIP orders. It is completely anonymous, meaning that the names of nurses administering the medications are not recorded. The purpose of using the AU Meds methodology is to increase our understanding of our complex medication administration system and processes and to focus on opportunities for improvement. Medication error or accuracy rates are important for gauging the scope of the problem, setting priorities for prevention strategies, and measuring the impact of those strategies.1 Four nurses and two pharmacists have been trained in the AU Meds observation technique. During that training, 133 actual observations occurred. The medication accuracy rate was 80%. Wrong time and technique errors were the
MEDS
most frequent that occurred. An error highlighted during training was the administration times for furosemide. According to UMMC’s policy concerning standard administration times, all diuretics are to be administered at 8 a.m. and 6 p.m. Currently when furosemide is ordered, CPMOE automatically times the medication for 10 a.m. and 10 p.m., thus causing wrong time errors. Medication observations will occur on every unit throughout the year. In order to have 95% confidence in our accuracy rates, a total of 5,141 observations must occur. The team’s goal is 6,000 observations before June 30, 2013. Observers will communicate with the nurse manager prior to the observations and information for team huddles will be distributed. When they arrive on a patient care area, they will confer with the charge nurse and ask to observe a nurse preparing and administing medications. This may involve more than one nurse and more than one patient. The observer will watch the process and will not interfere with the workflow of the nurse. If you would like additional information regarding AU Meds, please contact Paul Thurman via email address pthurman@umm.edu. References 1 Flynn, E. A., Barker, K. N., Pepper, G. A., Bates, D. W., & Mikeal, R. L. 2002. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. American Journal of Health-System Pharmacy. 59(5), pp. 436-446. 2 Murff, H. J., Pepper, G. A., Kuo, G. M. 2006. Medication Errors: Incidence and Cost. In Aspden, P., Wolcott, J., Bootman, L., & Cronenwett, L. (Eds.). Preventing Medication Errors. (pp. 105-111). Washington DC: National Academies Press.
New UMMC Shuttle Service UMMC has announced that a new shuttle service is now available free of charge to Medical Center employees. Developed and operated by the University of Maryland founding campus, the UMB shuttle covers three routes to the communities of Mount Vernon, Federal Hill, and the UM BioPark. The routes connect with Baltimore City public transportation such as the Charm City Circulator, the Maryland Transit Administration (MTA) MARC train, Light Rail, Metro Subway, and local bus service. A Medical Center (or University) ID is required to ride the shuttle. Please show it to the driver when you get on the shuttle. Printed shuttle schedules are still being produced by the campus and will be made available within UMMC. In the meantime, individual schedules are available on the UMMC intranet, and more information is located on the University website at www.umaryland. edu/shuttlebus. This site includes information about the NextBus transportation information system. This new shuttle service, which is supported in part by UMMC, is another sign of the continuing cooperation between the Medical Center and the UMB campus.
news &views Certification Corner Holistic Nursing Certification: A Journey to Support Body, Mind, and Spirit Diane Smith, MS, RN, AHN-BC, HTCP, SCN II, Cardiac Surgery Step Down
I have been a cardiac nurse for many years at UMMC, with multiple rounds of ANCC certification. In this season of my life, I found myself immersed in complementary and integrative knowledge. It seemed a natural fit to pursue holistic nursing, a journey which has given me a renewed passion for nursing. Holistic nursing is defined as all nursing practice that has healing the whole person as its goal. This means any nurse can practice holistically, within any specialty and any setting.
While my path has included multiple integrative modalities, modality skill sets are not required to be a holistic nurse. My journey began during the Medical Center Pain Task Force with a Reiki demonstration. I quickly took two Reiki classes. Then I moved to the structured and credentialed program of Healing Touch, which I continued through certification. My studies included clinical aromatherapy and energy psychology. This coursework occurred over two years
Wound Care, Ostomy Products, & Specialty Bed Fair October 3, 2012 8:00am—7:00pm Weinberg Round Room (W3L201)
and provided the 48 hours of education required to apply for the holistic nursing certification. Holistic nursing was recognized as an official nursing specialty in 2006 by the ANA. The path to certification can be found by visiting the American Holistic Nurses Association www.ahna.org and the American Holistic Nurses Certification Corporation www.ahncc.org. Once I completed the 48 hours of education, I submitted the application. The second step was a self-reflective assessment, which consisted of 3-4 short essay questions geared to the level of certification. Holistic nursing certification has three levels depending upon the nurse’s educational preparation. They are: HN-BC (associate degree); HNB-BC (bachelor degree); or AHN-BC (graduate degree). Following acceptance of both the application and the self-reflective assessment, I took a computerized exam, again based on the certification level. The exam covers a wide variety of content related to philosophy, theories, ethics, education, research, nurse self-care, communication, and the caring process. The questions require basic knowledge of humor, energy healing, herb safety, aromatherapy, nutrition, exercise, music, environment, and nursing presence. My time period from initial application to test results was six months. This preparation may seem overwhelming when most certifications require only one to two years of experience and an exam. However, I viewed the entire process as
a personal and professional journey that renewed my passion for healing. For example, the Healing Touch coursework provided new skills to help my patients and colleagues. The self-care focus in all of the holistic coursework has been even more valuable. I am challenged with each class, book, and mentor discussion to take care of myself physically, mentally, emotionally, and spiritually – a worthy but ongoing journey, to be sure. Nurses learn to care for the client in all of these dimensions, but too often the daily stretch to just meet the physical needs can be overwhelming. We became nurses to treat the whole patient. When nurses cannot meet these needs, burnout and stress can result. Holistic coursework helps nurses learn to protect and nourish their own heart and spirit and to support their colleagues with the same. With these skills, the nurse is in a better position to help the patient within all dimensions. My only regret is that I waited so long to acquire holistic skills. My mission now is to encourage other nurses to take this journey. The new AHNA Chapter that I co-lead with Cynthia Salmond, DNP, CRNP, is taking steps to provide one continuing education unit (CEU) at each of the meetings/classes. The classes are offered on three separate occasions each month and can support the education required for certification. Consider holistic nurse certification for your patients and families, and certainly for yourself.
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
For additional information contact: Joan Selekof at x. 8-6448, jselekof@umm.edu or contact your WOCN Nurse.
strategic goals. See page 2 for submission guidelines.
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Medical Orders for Life Sustaining Treatment (MOLST) Karen Kaiser, PhD, RN, Clinical Practice Coordinator, Division of Quality & Safety Diane Gregg, LCSW-C, MSSA, Director, Social Work & Human Services
The Maryland State Legislature passed a law that changes the way health care facilities, the emergency medical system, and health care providers in the state address and document patients’ end of life care wishes. While not yet fully implemented, you may see patients with a new form, Medical Orders for Life Sustaining Treatment (MOLST). The MOLST is replacing the MEIMSS EMS/DNR form and the Life-Sustaining Treatment Options form, the latter was primarily used in nursing homes. As a replacement, MOLST contains orders for both cardiopulmonary resuscitation (CPR) and life sustaining treatments. The intent of MOLST is to increase the likelihood that a patient’s wishes to receive or deny care are honored throughout the health care system. MOLST consists of two pages. The first page includes resuscitation status: a) attempt CPR (full code); b) no CPR, but intubate and artificial ventilation; c) no CPR, do not intubate; and d) no CPR. The second page provides patient specific information about situations other than cardiopulmonary arrest, such as: a) artificial ventilation; b) blood transfusion; c) hospital transfer; d) medical workup; e) antibiotics; f) artificially administered fluids and nutrition; and g) dialysis. MOLST should be completed after a discussion of the patient’s wishes with the patient or surrogate. An individual has the right to refuse to discuss or make a decision about their wishes, in which case CPR will be attempted and other treatments given. MOLST must be dated and signed by a physician or nurse practitioner with a Maryland license to be valid. Physicians with a training license may not sign MOLST. By law, MOLST is transferable between health care settings, even if the signatory is not on a facility’s medical staff. MOLST and MEIMSS EMS/DNR forms are durable and do not expire. With this new law, the Maryland Health Care Decisions Act is unchanged. Differences between an individuals’ advance directive (living will) and MOLST should be discussed with the patient or the surrogate. Surrogates are defined in our policies PROE-102 and PROE103 (see Table 1), which incorporate the requirements according to Maryland’s Health Care Decisions Act.
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When a patient is admitted with MOLST, obtain a copy and place it in the Advance Directives section of the chart. It is expected that we will comply with MOLST unless it is medically inappropriate and discussed with the patient. Upon discharge, if a patient has MOLST, a copy is provided to ambulance transport, sent to the health care facility, given to the patient, and retained for the medical record. Pilot testing of the MOLST process at UMMC started in February for the surgical oncology population. Stay tuned for further information as the state regulations are finalized, and as we implement MOLST throughout the Medical Center. Table 1
Surrogate Decision Makers Policy #
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PROE-102
Informed Consent - Who May Give Substitute Consent for Incompetent Adult
PROE-103
Informed Consent - Who May Give Children
Effective Models for Hourly Caring Rounds Inpatient settings
Ambulatory, Outpatient, and ED settings
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PPD
Pain Positioning Personal needs Possessions
Pain Plan of care Delays
news &views Core Measures What’s Next? Anna Marie Moko, MBA, BSN, RN, Quality Measures Coordinator and Sylvia B. Daniels, BSN, RN, Manager, Regulatory Compliance, Division of Quality & Safety
The information in the table below describes the six VTE measures and the rationale. Data collection on all VTE measures started in January 2012 to assess our current compliance and to identify opportunities for improvement. The results are shown here: 100% 80%
In January 2013, the Medical Center, like other hospitals in Maryland, will be required to collect and report data to the Maryland Health Care Commission (MHCC) for two new sets of core measures – venous thromboembolism (VTE) and stroke. This article will focus on the VTE measures. Information regarding the stroke measures will be presented in a future article. MHCC is the health regulatory system that drives the quality of services provided to the citizens of Maryland. In this vein, they determine the evidence-based performance metrics that must be collected, reported, and improved upon by Maryland hospitals. We currently report data to MHCC regarding the following: ◗◗ treatment of surgical patients; ◗◗ patients admitted with the diagnosis of heart failure, heart attack, pneumonia, or pediatric asthma; ◗◗ patients requiring immunizations; and ◗◗ patients receiving care in our emergency departments.
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The data suggest that accurate and complete documentation of care given is the biggest challenge for complying with the VTE measures. The nurse plays a key role in the improvement in the following areas: ◗◗ Documentation of the placement of mechanical prophylaxis – antiembolism stockings and pneumatic compression devices; ◗◗ Administration of chemical prophylaxis (Lovenox, Heparin, Warfarin) as ordered and in a timely fashion; ◗◗ VTE prophylaxis must be documented as administered on the day of or the day after hospital admission and on the day of or the day after the initial admission or transfer to intensive care; ◗◗ Documentation of the reason why ordered mechanical prophylaxis was not
Description
carried out on the nursing daily profile or critical care flow sheet; ◗◗ Documentation of the reason chemical prophylaxis was not administered on the eMAR; and ◗◗ Verification that patients with confirmed VTE that are discharged home on Warfarin therapy receive written discharge instructions that address compliance issues, dietary advice, followup monitoring, and information about the potential for adverse drug reactions and interactions.
Several years ago, Mangla Gulati, MD, a hospitalist in the Department of Medicine, began to focus on improving VTE prophylaxis at the Medical Center. She facilitated the development of the VTE assessment in PowerChart, began to educate the medical staff, and formed the VTE Prevention Committee. This committee is a multi-disciplinary group composed of physicians, clinical pharmacists, nurses, quality staff, and information technology staff. The charge of this group is to identify, prescribe, and ensure appropriate evidencebased prophylaxis for all hospitalized patients. The committee meets quarterly to review the current state and practices of VTE prophylaxis at the Medical Center. This group will play a pivotal role in the Medical Center achieving top decile performance on the VTE core measures. Rationale
VTE 1
Number of patients that receive VTE prophylaxis or have documentation why VTE prophylaxis was not given the day of or the day after a hospital admission.
VTE 2
Number of patients that receive VTE prophylaxis the day of or the day after the initial admission or transfer to intensive care.
VTE 3
Number of patients diagnosed with confirmed VTE and received an overlap of intravenous or subcutaneous anticoagulation and Warfarin therapy.
VTE 4
Number of patients diagnosed with confirmed VTE who received intravenous unfractionated Heparin (UFH) therapy dosages and had their platelet count monitored using defined parameters, such as a nomogram or protocol.
VTE 5
Number of patients diagnosed with confirmed VTE that are discharged to home on Warfarin therapy that receive a written discharge instruction that addresses all four criteria: 1. compliance issues; 2. dietary advice; 3. follow-up monitoring; 4. information about the potential for adverse drug reactions and interactions.
Anticoagulation therapy poses risks to patients and often leads to adverse drug events because of complex dosing, required follow-up monitoring, and inconsistent patient compliance. Patient/caregiver involvement through clear and understandable instructions may reduce the risks of adverse drug events.
VTE 6
Number of patients diagnosed with confirmed VTE during hospitalization (not present on admission) who did not receive a VTE prophylaxis between the hospital admission and the day before the VTE diagnostic testing order date.
Pulmonary embolism, in spite of formal guidelines, is the most common preventable cause of death among hospitalized patients.
Symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) may develop even before diagnosis is suspected on hospitalized high risk patients. The best approach is for every patient to be evaluated for primary prophylaxis, since prevention of DVT is essential to reducing the morbidity and mortality associated with PE. Clinical trials have shown that UFH management by weight-based/ activated partial thromboplastin time (aPTT) adjusted protocols achieve a therapeutic aPTT more rapidly than with standard UFH dosing without increasing major bleeding. Platelet count monitoring is recommended for all patients treated with UFH to detect heparin induced thrombocytopenia.
Source: Specification Manual for the Joint Commission National Quality Core Measure V4.1-1
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Hourly Caring Rounds E v e ry H o u r . . . E v e ry Day. . . E v e ry Pat i en t
Hourly Caring Rounds, continued from page 1. between nursing excellence and rounding. The team also developed a skit that was presented at Nursing Grand Rounds to highlight the differences between providing care with and without a focused approach to address patient needs.
Education focused on the basics. This included strategies to meet the needs of our patients and families, strategies that drive our scores in patient safety metrics such as falls and pressure ulcers, and strategies that drive patient satisfaction in ways that prove to our public that we deliver safe and patient-centered care. Over the course of three days, the team presented to a multitude of nurses and other patient care services staff members in a formal session and during small group drop in discussions that were scheduled in the Weinberg atrium hallway. Many areas have already made plans to implement the intent of hourly caring rounding to meet the needs of their specific populations. (See right) In order to measure our performance with this important tactic to enhance patient safety and satisfaction, we will be auditing compliance and quality. For example, hourly caring rounds will be audited toward the end of each shift. The audit may be completed by the charge nurse or delegated to another nurse, PCT, or unit secretary. The auditor is checking to ensure that a care provider completed hourly caring rounds and initialed the documentation board provided for each patient care area. The audit tool is reviewed and entered continued on page 13.
Strategies To Implement Hourly Caring Rounds At UMMC The following examples are provided from various patient care areas at UMMC that have begun the planning, education, and integration of hourly caring rounds into daily clinical practice. 13 East/West The staff will alternate hours, with the nurses doing the even hours and the PCTs doing the odd hours. In addition, charge nurses and senior clinical nurses will make rounds at various times throughout the day and check for compliance. Stacey Trotman, RN, CMSRN Adult ED The Adult ED is developing a process improvement project aimed at decreasing the rate of patients who leave without being seen (LWBS). This can lead to delays in care and poor outcomes, as patients who are potentially in need of emergency services leave before they receive treatment. Lack of information and poor interactions with hospital employees have been recognized as reasons that patients choose to leave the ED prematurely. We will implement hourly caring rounds in the waiting room to give patients individualized information and to hopefully improve patient perceptions of their interactions with staff members and their ED experience. Patient safety will undoubtedly be enhanced by the regular presence of a clinician in the waiting room who could potentially discover a deterioration in patient status and expedite treatment. We believe there will be other advantages, such as increased comfort, decreased anxiety, and improved patient satisfaction. Erin Ruark, BSN, RN, CEN Endoscopy The front desk secretary will be responsible for hourly caring rounds. A tool will be utilized to document that families and escorts in the waiting room have been updated with a patient status. Our procedures are between 30 to 90 minutes long. Procedure RNs are responsible for letting families know when patients are in recovery and approximately how long they need to be there. Grace Grasso, RN
Greenebaum Cancer Center Our hourly caring rounds in the inpatient units (N8/9W and BMT) will be using the 4 Ps (pain, positioning, possessions, and personal needs). Each shift, caring rounds will be assigned to specific staff members based on staffing patterns for that shift. A combination of nurses and techs will be making this happen around the clock. The unique thing we are doing in these areas is to simultaneously formalize our bedside handoff for both PCTs and nurses. The handoff will add an additional 4 Ps (personal introductions, pRN effectiveness, priorities, and plan) at shift change. In the Stoler Pavilion, there are multiple waiting areas and often unavoidable delays for lab results or chemotherapy to be prepared. We will implement caring rounds aligned more with the PPD model (pain, plan, and delays). Every hour the clinic is open, a designated staff member will be checking with the patients in both waiting areas, as well as those seated in the infusion area to make sure they are as comfortable as possible. Patients who are waiting can be offered information, and those who are ready to move from one area to the next can be offered guidance or assistance. Ann S. Rigdon, MS, RN, OCN NICU Nurses suggested we adopt a model of 5 Ps (Pain, Positioning, PIV Check, Parents, Pumping). Some of our nurses developed a script to accompany the patient/family hourly rounding brochure and introduce the rounds. The script reads as follows: “For the safety of your baby, you can expect that we will be doing Hourly Caring Rounds that will include: checking your baby’s IV (lines), checking your baby’s position, assessing for any pain, and checking on you when you are at the bedside.” We intend to end each interaction with the statement, “Is there anything your baby needs and is there anything I can do for you?” Chris Byerly, BSN, RNC-NIC Evelyn Jordan Center The Evelyn Jordan Center (EJC) has initiated a relationship based care initiative which includes hourly caring rounds. The nurses and administrative staff are talking with patients in the waiting rooms and exam rooms. We ask patients if they are comfortable and address their needs. We give them updates
news &views on the waiting time. This initiative was started because patients were concerned that they were not informed about wait times. The EJC hopes to improve waiting time in the clinic and improve patient satisfaction. Margaret Burns, BA, RN SICU Hourly caring rounds are not a new concept to the SICU, as this process was a performance improvement project that was initiated about two years ago. With the introduction of the hospital-wide hourly caring rounds, we will take this opportunity to re-educate our staff about the intent of hourly rounds, specifically about the importance of the safety and service this initiative helps to provide to our patients and families. We do walk into every patient’s room every hour and document that we did so, but do we specifically ask the patient about the 4 Ps each time? This will be the focus of our education and part of the rejuvenation of this important initiative. We have taken it a step further to help with compliance to introduce a SICU process to hourly caring rounds. Nurses will round at 7 a.m. and 7 p.m. with bedside report and then will round on the even hours. PCTs and CNAs will round on the odd hours. In addition, the unit secretaries will round on the patients after our Quiet Hour. We will also work together with our respiratory and rehabilitation therapists to assist with hourly caring rounds, as this is a collaborative effort. This plan is a work in progress. We will collect feedback from our staff on the process itself and discover ways to improve how we operationalize hourly caring rounds in the SICU. Our primary goal is to increase patient and family satisfaction, improve safety, and make the process meaningful to our staff. Meredith Huffines, BSN, RN MICU The MICU is incorporating their unit secretaries into their process of hourly caring rounds. It is a customer service approach that has already shown a reduction in overhead paging for non-emergent patient care needs. An additional benefit for the unit secretaries is the excitement in being part of the team approach for this initiative. Cheryl Coale, BSN, RN
General Pediatrics The General Pediatrics Practice Council has owned hourly caring rounds on our unit. We have planned a celebration to coincide with the week of the hospital-wide kick off. This will include celebrations on Monday, Wednesday, and Friday that week during change of shift. A round-shaped food, such as bagels, munchkins, or cookies, will be served each of the days. Our charge nurse will also be handing out round life savers on the hour. Music with a “rounding” theme will be played on the hour. Ivy Klein, MS, RN, CNL, CPN Gudelsky 5 West In order to expedite the implementation of hourly caring rounds on my unit, and after talking to staff members, it was decided in May 2012 to create an ad hoc committee. This enabled buy in from the entire staff so that everyone would hold their peers accountable for the implementation and success. The committee members are responsible for making certain rounds are performed on both shifts and completing daily audits. They are identified as unit champions for this hospital-wide initiative. A couple of the key things the group is focusing on include improving patient satisfaction scores, such as staff responsiveness and answering call lights in a timely manner, and decreasing our unit falls rate. The committee consists of both RNs and PCTs. Presently we are in the process of developing laminated scripts with the 4 Ps that can be easily attached to ID badges. Shirley Tindal, MSN, RN, CNRN 10 East/11 East
On 10 East & 11 East, three committees combined to work on hourly caring rounds to ensure sustainability and accountability. Our process for hourly caring rounds will be incorporated with the bedside reporting process. During this communication at the bedside, the hourly rounding process for the day will be introduced and explained to the patients and families. Shawn Hendricks, MSN, RN
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Hourly Caring Rounds, continued from page 12. into the hourly caring rounds unit report spreadsheet. This tool will calculate the unit’s compliance with hourly caring rounds automatically for ease of reporting. In addition, the nurse manager or designee will interview patients and families to ensure that hourly caring rounds occur as expected, and that the patient’s needs are met proactively. An important factor for success in the implementation of hourly caring rounds is the engagement of all nurses in the process. Nurses will lead the charge as we bring this initiative to our patients and families. The team feels strongly that even though nursing will be the key component of hourly caring rounds, other care providers should participate. For example, nurse practitioners can meet the parameters of hourly caring rounds when assessing patients and can sign off for the hour. In addition, physical therapists assess a patient’s pain, positioning, and toileting skills, and they place personal possessions within close proximity each time they work with a patient. The intent of hourly caring rounds is met during these interactions, and they can sign off the board for the hour. Respiratory therapists are another group of care providers that have contact with patients and families and can easily meet the requirements of hourly caring rounds through their interactions and assessments. Resources to help our patient care teams develop their approach to rounding include a specific intranet page with educational materials, scripting for managers, audit tools and expectations for collecting data, and a video of the actual presentation held in the auditorium on July 16, 2012. In addition, there is a dedicated email address – hourlycaringrounds@umm.edu – that can address questions, concerns, and ideas specific to this initiative. So, please go out and round. Hourly caring rounds is our opportunity to connect with our patients and families, improve safety and satisfaction, and improve our effectiveness as care providers every day.
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Hourly Caring Rounds E v e ry H o u r . . . E v e ry Day. . . E v e ry Pat i en t continued from page 13.
FAQs “Words that Care” for Managers and Supervisors “I’m already in the patient’s room at least every hour.” I understand that you are in the patient’s room completing tasks and interventions, sometimes even more frequently than every hour. Hourly caring rounds are the purposeful time each hour where we step aside from our clinical tasks and “to do” lists and take the 1-2 minutes to ask the patient what they need from us. Those brief moments give the patient or family member the opportunity to have your undivided attention and have their needs met proactively. “What if I am busy with another patient or off the floor and cannot complete the caring rounds that hour?” It’s important to team up with your colleagues and support staff to share the responsibility of hourly caring rounds on all patients in your unit. If you are not available to round on your patient, reach out to your PCT, another RN, charge nurse, or even another support staff member who can. Remember, almost anyone can check on the patient and ask them if they need anything. Hourly caring rounds work because they are consistent, and the patient can relax knowing that someone will always be there to check on them. When emergencies happen and an hourly caring round is missed, acknowledge it and apologize to the patient. Reassure them that they were not forgotten and continue to perform rounds.
“I did hourly rounds at noon and then 13:30. My patient became upset that I was late.”
“My patient doesn’t want hourly rounds.” Many patients want to rest and do not want frequent interruptions. Have this discussion with them when you assume their care. Explain to the patient what hourly caring rounds are and their purpose. Be flexible with rounding according to the patient’s needs. For example, some patients may not want hourly caring rounds at night. If a patient doesn’t want hourly care rounds at all, be sensitive to this request and remember that this is for the patient. When a new nurse assumes care of that patient, they should confirm with the patient that they still do not want the hourly caring rounds.
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If the patient is upset, it is important to first use service recovery (Act with HEART) to better understand specifically why the patient is upset and give us the opportunity to acknowledge and apologize that they are upset. Once the patient has been calmed down or is no longer upset, take a few moments to discuss their expectations of hourly caring rounds. Try to reach a compromise with them on when rounding will take place. Reassure the patient that you or one of your colleagues will be there to check on them within each hour to meet their needs, and that they can always utilize the call bell in between rounds if they need someone at that moment.
UMMC is dedicated to keeping you safe by providing the best care possible. Sometime during every hour our health care team will check on you and see what we can do to meet your needs.
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Reminders: ◗◗ Hourly caring rounds, when performed correctly and with the patient in mind, will result in the patient’s needs being anticipated and a decrease in call bell usage. ◗◗ Hourly caring rounds do not take the place of responding to the patient’s immediate needs. If the patient needs something shortly after the hourly caring rounds were completed, the nurse or another staff member should still meet that request and provide care as usual.
news &views Hourly Caring Rounds Team Paul Thurman, MS, RN, ACNPC, CCNS, CCRN, CNS R Adams Cowley STC
Ann Rigdon, MS, RN, OCN Greenebaum Cancer Center
Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN R Adams Cowley STC
Anne Naunton, MS, RN-BC CPPD
Julie Caprio, BS, RN, SCNI CCU
Christine Byerly, BSN, RNC-NIC, SCN II NICU
Meredith Huffines, BSN, RN, SCN II SICU
Stacey Trotman, RN, CMSRN, SCNII 13 East/West
Tonnette Branch RN, CMSRN, CNII 13 East/West
Lucy Miner, BSN, RN, PCCN, SCNII Medicine/Surgery Division
Timothy Jones, BSN, RN, SCNI Multitrauma Critical Care
Margot Munzel, BSN, RN Weinberg 5
Sarah Baker, RN, ONC, CNII Orthopedics
Gwen Fraling Administrative Assistant
Manager Advisory Team Laura Hearson, MS, RN, OCN BMT/N8W/9W
Kerry Mueller, MBA, RN, CCRN MICU
Mary Jo Simke, MS, RN Pediatrics
Diane Michalek, MS, RN Ambulatory Services
David Wong, BSN, RN Perioperative Services
Tonja Bell, MS, RN Supplemental Staffing
Kathryn Bishop, MS, RN Radiology
Denise Choiniere, MS, RN Facilities
Joan Selekof, BSN, RN CWOCN
Lynn Armstrong, MS, RN Neurotrauma
Shirley Tindall, MSN, RN, CNRN Neurocare
Donnica Major, MS, RN, ONC Radiation Oncology
Connie Noll, MA, BSN, RN-BC Psychiatry
R Adams Cowley Shock Trauma Center (STC) Infection Reduction Collaborative In Delhi, India Yields Positive Outcomes Linda Byrne, MS, RN, SCN II, Neurotrauma ICU, STC
In 2009, the R Adams Cowley Shock Trauma Center (STC) initiated a strong relationship with the JPN Apex Trauma Center (JPN) in Delhi, India after nurses from the STC were invited to speak and serve as chairpersons for the nursing track at the conference, “Trauma 2009 International Congress, CME cum Live Workshop and Second Annual Conference of the Indian Society for Trauma and Acute Care.” In February 2011, Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN, coordinated efforts to have several of the nurses from our STC Quality Council join forces with nurses in India to establish an infection reduction collaborative. This was accomplished through video conferencing. Our first initiative was to focus on the reduction of CLABSI rates. During our first video conference, we discovered that infection rates were not publicly displayed for the nursing staff at JPN. We shared our experience with quality boards and provided examples as a strategy to increase awareness of infection rates and to provide education. As a result, JPN nurses have developed quality boards and posted them on their units. In the next step of this collaboration, we discussed the significance of documenting on a central line insertion checklist. The importance of holding the entire health care team accountable for maintaining sterility was emphasized, and this included “speaking up” when sterility was not maintained. We advised the nurses to wear a mask and cap when assisting the physicians with line insertions. Over the past several months, we helped JPN nurses develop more stringent audit tools to monitor this quality initiative. This was in addition to providing the best evidence for catheter insertion and line maintenance practices. In the last issue of News & Views, we reported that through this collaboration, the Neurotrauma Critical Care Unit at JPN had a zero CLABSI rate for the month of January 2012. It is not surprising that JPN continues to produce positive outcomes. During our video conference in July 2012, Deepak Agarwal, MD, Associate Professor of Neurosurgery at JPN and many members of the nursing staff, informed us that they continue to see a reduction in CLABSI associated with consistency in filling out the central line insertion check list located on their line carts. Unfortunately, there are a few patients that have developed CLABSI. However, these patients did not have the central line checklist completed upon insertion. As a consequence, they are re-directing their efforts to be vigilant in achieving 100% compliance in the completion of this critical piece of documentation.
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Honorable Mention
Trauma Resuscitation Unit (TRU) Shares Charge Nurse Initiative at National and Local Conferences Lynn Gerber Smith, MS, RN, SCN II, TRU, STC
On April 11th, 2012, Sue Fishel Ramzy, BSN, RN, SCN I, Lynn Gerber Smith, MS, RN, SCN II, and Theresa DiNardo, MSN, RN, CCRN, Nurse Manager, presented
TRU Nursing Staff Share Their Trauma Knowledge Lynn Gerber Smith, MS, RN, SCN II, TRU, STC
The nursing staff of the R Adams Cowley Shock Trauma Center Trauma Resuscitation Unit (TRU) have been busy presenting at state and national conferences in the first half of 2012. Below is a listing of the many presentations given by TRU nurses: ◗◗ January 27, 2012 - Andi Ball, RN, CCRN, CEN, SCN I and Diana Clapp, BSN, RN, CCRN, CEN, NREMT-P, SCN II presented, “EMS Communication and Assessment” at Winterfest, an annual pre-hospital conference held on Tilghman Island, MD. ◗◗ February 3, 2012 - Lynn Gerber Smith, MS, RN, SCN II presented, “Things You Were Never Taught: Case Studies in Trauma Patient Care” at the Emergency Medicine & Trauma Conference held at the North Mississippi Medical Center in Tupelo, MS.
“Charge Nurse Empowerment Demonstrates Improved Unit Flow and Patient and Staff Satisfaction” at the poster sessions of the Society of Trauma Nurses annual meeting in Savannah, GA and the 2012 Maryland Emergency Nurses Association annual meeting held in May in Linthicum, MD. The poster, developed with the assistance of Kristin Seidl, PhD, RN, Director of Nursing Outcomes, Research, and Evidence-based Practice, highlighted the successful redesign of the TRU charge nurse role. The results of the redesign showed a remarkable decrease in patient length of stay from 12 hours to 5.9 hours, which is below the targeted goal of 6 hours. Patient satisfaction scores were in the 99th percentile for 8 consecutive quarters. In addition, the nursing turnover rates were less than 2%. The results also demonstrated an overall increase in patient admissions to the trauma center. ◗◗ February 25, 2012 - Andi Ball, RN, CCRN, CEN, SCN I presented, “EMS Communication and Assessment” and Diana Clapp, BSN, RN, CCRN, CEN, NREMT-P, SCN II presented, “Case Review: Maritime Trauma” at the National Collegiate EMS Foundation held in Baltimore, MD. ◗◗ April 13, 2012 - Suzanne Sherwood, MS, RN, CN II, Assistant Professor (UMSON) presented, “Orthopedic Trauma: More Than Broken Bones and Substance Abuse and Trauma: A Deadly Combination” at “A Slice of NTI” held in Las Vegas, NV. ◗◗ April 14, 2012 - Andi Ball, RN, CCRN, CEN, SCN I and Diana Clapp, BSN, RN, CCRN, CEN, NREMT-P, SCN II presented, “Anticoagulants: A Necessary Evil” at EMS Care held in Ocean City, MD. Andi Ball shared this presentation with providers around the state via an EMS evening broadcast from the Trauma Center on May 4. ◗◗ May 3, 2012 - Lynn Gerber Smith, MS, RN, SCN II presented, “The Care of the Adult Trauma Patient with Special Needs” and Suzanne Sherwood, MS, RN, CN II, Assistant Professor (UMSON) presented, “Care of the Morbidly Obese Trauma Patient” in Gulfport, MS at the Mississippi Coastal Trauma Care 11th Annual Trauma Symposium.
Pictured in front of their poster in Savannah are (from left to right): Lynn Gerber Smith, MS, RN, SCN II, TRU Theresa Dinardo, MSN, RN, CCRN, Nurse Manager, TRU Sue Fishel Ramzy, BSN, RN, SCN I, TRU
◗◗ May 23, 2012 - Suzanne Sherwood, MS, RN, CN II, Assistant Professor presented, “Substance Abuse and Trauma: A Deadly Combination” at the annual AACN National Teaching Institute (NTI) held in Orlando, FL. ◗◗ June 12, 2012 - Ellen Plummer, DL, MJ, MBA, MSN, RN, CCRN, SCN II presented the webinar, “Hide and Seek in Orthopedic Trauma: Reducing the Likelihood of Missed Injuries” for the National Association of Orthopedic Nurses. ◗◗ June 14, 2012 - Suzanne Sherwood, MS, RN, CN II, Assistant Professor (UMSON) presented, “Elder Abuse: Broken Bones, Broken Hearts, and Broken Trust” for the Victim Services Unit, Frederick County Sheriff ’s Office, Frederick, MD. This was attended by health care providers, clergy, police officers, and volunteers that work with the elderly.
news &views Abstracts Accepted For The 2012 ANCC Annual Magnet Conference In Los Angeles, CA. Congratulations to the Medical Center staff that had the following abstracts accepted. Can a Brief Intervention Increase Awareness of Disruptive Behavior in the Workplace? (Poster Presentation) L. Rowen, DNSc, RN, FAAN, G. Raymond, MBA, MS, RN, K. Seidl, PhD, RN, C. Cafeo, MS, RN & R. Hercenberg, BA
Disruptive behaviors and workplace violence are a growing concern in health care. The transformational nurse leader can have significant impact on promoting civility in the workplace by raising organizational awareness through education and dialogue. Participants in this type of intervention demonstrated significant increases in their own awareness through pre and post test validation. Delirium in Trauma Patients: Prevalence, Predictors, and Evidence-based Guidelines (Podium Presentation) K. Von Rueden, MS, RN, CNS-BC, FCCM, B. Walizer, BSN, RN, CCRN, K. McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN, P. Thurman, MS, RN, ACNPC, CCNS, CCRN, CNRN, H. Son, PhD, RN, T. Blacklock, MS, RN, CRNP, J. Merenda, BSN, RN, S. Hake, MS, RN, S. Dalenkoff, BSN, RN & J. Anderson, MSN, RN
This presentation describes the process that occurred and outcomes achieved when direct care nurses and advanced practice nurses collaboratively questioned practice, engaged in nursing research, and then established an evidence-based guideline to improve patient care and clinical outcomes related to acute delirium in the trauma population.
Impact of Nursing Council Participation in Reducing Central Line Associated Blood Stream Infections (Poster Presentation) K. McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN, K. Von Rueden, MS, RN, CNS-BC, FCCM , P. Thurman, MS, RN, ACNPC, CCNS, CCRN, CNRN, B. McDavid, BSN, RN, R. Gilmore, RN, & T. Bayne, BSN, RN
This presentation describes how Nursing Councils within a shared governance structure, staff nurse champions and advanced practice nurses led a health care team in implementing evidence-based (EB) central line (CL) insertion and maintenance strategies to substantially reduce central line associated blood stream infection (CLABSI) in trauma patients. Improving the Effectiveness of Diabetes Care Visits Through Computer-Assisted Analysis of Blood Glucose Readings (Poster Presentation) C. Armstrong, RN, Center for Diabetes and Endocrinology
To improve the effectiveness of provider decision making in the development of diabetes treatment plans, a computerassisted analysis of self-monitored patient glucometer data was pilot tested during visits to an ambulatory diabetes clinic. This nurse driven innovation included meter selection, software installation, multi-disciplinary staff training, and work flow modification.
Professional Advancement Model Promotions Congratulations to the following UMMC nurses that were promoted in July 2012. Senior Clinical Nurse I Carla Kanaskie, BSN, RN Medical Intermediate Care
Derek Eckenrode, BA, RN* Medical Intermediate Care
Jeffrey Broski, BSN, RN, CCRN Multi Trauma Critical Care
Jennifer Motley, BSN, RN Multi Trauma Intermediate Care
Kimberly Erwin, BSN, RN, CCRN, CPEN Maryland ExpressCare
Kimberly Stago, MS, RN, CNL Cardiac Surgery Step-Down
Kristen George, MPH, BSN, RN Multi Trauma Critical Care
Latisha Jones, BSN, RN 11 East
Laura Lunz, BSN, RN, OCN Radiation Oncology
M. Tracey Penaloza, BSN, RN, CNOR General Operating Room
Melanie Priest, BSN, RN Interventional Radiology
Renee Kwok, RN, OCN* Radiation Oncology
Sheila Marshall, RN**
The Nurse Practitioner Critical Care/Trauma Post-Graduate Residency: An Innovation to Improve Novice Transition to Practice (Virtual Poster) D.L. Schofield, DNP, CRNP & C.A. McComiskey, DNP, CRNP
Nurse Practitioners have demonstrated competent and efficient patterns of care; they are in great demand in U.S. hospitals. The transition from novice-to-expert provider role is challenging for multifactorial reasons. Moved by the Institute of Medicine recommendations, we proposed a postgraduate critical care residency to ensure competency in these areas.
Lisa Rowen Elected to MHA Executive Committee
Lisa Rowen, DNSc, RN, FAAN, Senior Vice President and Chief Nursing Officer, Nursing and Patient Care Services, was elected to the Maryland Hospital Association’s executive committee. Rowen will serve a one year term as CEO councilor-at-large and will be eligible for re-election to two additional one year terms in this position. Source: The Baltimore Sun, Sunday, July 29, 2012
Medical Intermediate Care
Stacey Uddeme, RN, CPEN* Pediatric Emergency Department
Stacie Mann, RN, CCRN* Multi Trauma Critical Care
Tasha Zochert, RN, CCRN* Select Trauma Critical Care
Tatiana Asuquo, RN** General Operating Room
Teresa Turska-Hughes, BSN, RN, CCRN Cardiac Surgery Intensive Care
Tiffanie Moran, BSN, RN, CCRN Medical Intensive Care * Enrolled in BSN program ** Commitment to enroll in BSN program
Senior Clinical Nurse II Lucy Miner, BSN, RN, PCCN Division of Medicine & Surgery
Mary Patricia Wall, BSN, RN, CCRN Interventional Radiology
Patricia Gent, MSN, RN, CCRN Endoscopy
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2012 Student Nurse Residents Present Poster Summit in Weinberg Atrium Cyndy Ronald, BA, Manager, SON Partnership Programs, CPPD
The Weinberg atrium was the focal point of activity on July 26–27, 2012 when the University of Maryland Medical Center Student Nurse Residents (SNRs) presented their annual poster summit. Each year approximately 45 applicants from various nursing schools throughout the country are selected into the SNR program after a rigorous application, screening, and interview process. The SNR program is designed to enhance and foster the professional growth of the student nurse throughout his/her senior year of nursing school. The main objective is to bridge the gap for the student nurse from their final year in nursing school into their novice year of nursing. The SNRs develop their professional and leadership qualities by participating in the poster presentations. Topics for the posters are selected after thorough discussions with the nursing staff on the units where the SNRs are assigned and are based on the educational needs of the patients, families, or staff. The feedback from the SNRs and nursing staff, as a result of the poster summit experience, is consistently favorable.
Sample of SNR Poster Topics Kangaroo Care for Procedural Pain Management for Infants Euglycemic Control in Critically Ill Patients Syncardia Total Artificial Heart (TAH) Increasing Patient Satisfaction with Hourly Caring Rounds Full Outline of UnResponsiveness (FOUR) Score: More Appropriate Than the Glasgow Coma Score in the ICU Setting Prevention of Ventilator Associated Pneumonia (VAP) in Adult Critical Care Units TAVR: An Innovation in Cardiac Surgery The Monitor That Cried Wolf: Combating Alarm Fatigue Effects of Integrative Medicine on Pain, Anxiety, and Stress in Hospitalized Patients Oral Mucositis Management in BMT Patients Extra-Corporeal Membrane Oxygenation (ECMO)
news &views We Discover Journal Club Hot Topic Patricia Woltz, MS, RN and Luizalice Lima, MS, RN-BC, Professional Development Coordinators, Clinical Practice & Professional Development
The Journal Club reviewed the article,
“Testing the Effectiveness of the Amputee Mobility Protocol-A Pilot Study.”1
This pre-post observational study evaluated the effects of a standardized mobility protocol (AMP) on the functional mobility and length of stay (LOS) outcomes of adult patients on a vascular unit who underwent either above knee (AKA), below knee (BKA), or transmetatarsal (TMA) surgery. The study’s theoretical framework was Roy’s Adaptation Model, which describes lifestyle changes and adaptation to altered body image, such as occurs with loss of limb. Data for the pre-intervention group were obtained by retrospective chart review of 30 patients who had been admitted November 2004 to March 2005. Post-intervention data were collected concurrently from 14 patients who underwent surgery November 2005 to March 2006. The interdisciplinary AMP intervention developed by the multidisciplinary team included: computerized physician order entry sets; triggers for initiating early PT referrals; staff education; early placement of trapeze equipment and regular use of assistive devices; tools to motivate and inform patients about mobility expectations; and individualized plans of care for pre-op and
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post-op functional and strength training. Functional mobility was measured pre-op and at discharge using a shortened version of the Functional Independence Measure (mFIM). Descriptive statistics with mean percentages were used to evaluate the differences in mFIM scores and LOS. Findings showed that after implementation of the AMP on the vascular unit, patients had improved mFIM mobility scores and more frequent PT consults. Also, the post-AMP group had fewer thrombotic post-op complications (0/14 post vs. 4/30
pre-AMP). However, while compared to pre-AMP, LOS decreased post-AMP in the TMA group (0.7 days) and increased post-AMP in the AKA and BKA groups (2.7 and 7.1 days respectively). The study concluded that multidisciplinary collaboration on the development and implementation of mobility standards of care may positively affect patient outcomes. Major limitations of this pilot study were its small sample size and lack of a concurrent control group. Group characteristics were not provided, so it is unclear if groups were comparable. The authors were unable to explain why LOS increased in two out of the three groups, but suggested that comorbidities may have played a role. More research is needed to understand the effects of AMP that would include collection of demographic and clinical predictors, as well as cost and discharge disposition outcomes.
Discussion: Attendees agreed that mobility should be viewed as part of patient treatment and healing, particularly on surgical units, and they discussed the importance of standardizing mobility protocols for patients at the Medical Center. They agreed that the value of the Marzen-Groller study lies in the methods and procedures for developing the interdisciplinary mobility protocols. In partnership with prescribers, PT staff, and nursing, development and routine implementation of strategies that promote early activity can benefit functional recovery of at-risk patients. Clear instruction for both staff and patients around activity orders can be beneficial, like the UMMC orthopedic unit that uses strict mobility protocols for their patient populations. Nursing staff can increase the mobility of patients by helping to define and communicate the individualized daily goals of patients in conjunction with their families. The focus on embedding “promote life” and “go the distance” (Roy’s model) on the patient’s daily life may help with feelings of loss and fear with a refocus on living. References 1 Marzen-Groller, K., Tremblay, S., Kaszuba, J., Girodo, V., Swavely, D., Moyer, B., Bartman, K., Carraher, W., & Wilson, E. (2008). Testing the effectiveness of the Amputee Mobility Protocol: A pilot study. Journal of Vascular Nursing, 26 (3), 74-81.
online at http://www.umm.edu/nursing/newsletter.htm on the UMM Intranet at intra.umm.edu/ummc/nursing-dept/newsviews.htm
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Clinical Practice Update
50% Rule - Example #1 Medication was Due at 14:00
This example applies to a dose ordered every 8 Hours
Time:
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Should the the 22:00 22:00 Should dose dosebe beskipped? given?
But, it was given at 16:15
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2nd Half
ANSWER: This dose would be given at scheduled administration time. (22:00) since the last dose was given in the 1st half of the interval. • Give the medication as soon as possible. • Document the reason that it is late.
50% Rule - Example #2 Medication was Due at 14:00
This example applies to a dose ordered every 8 Hours
Time: 9
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GIVE DOSE
1st Half
Should the 22:00 dose be skipped?
But, it was given at 19:35
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ANSWER: This dose would be skipped at the scheduled administration time (22:00) since last dose was given in the 2nd half of the interval. New Requirement!
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Document as “Not Given” and “Not Appropriate at this Time” Notify a provider of the missed dose & document the name of the provider notified. Then, follow the next scheduled administration time for subsequent doses—they will be back on schedule.
REMEMBER: Whether you give or skip the 22:00 dose the next scheduled admin time remains 06:00