News & Views: Spring 2016 by UMMS

news views Spring 2016

A Publication of the Department of Nursing and Patient Care Services University of Maryland Medical Center

Lisa Rowen’s Rounds: CNO Award for Team Excellence –

The Medical Intensive Care Unit

The CNO Award for Team Excellence is presented to a team that has consistently demonstrated excellence in teamwork to provide extraordinary care to patients, families, and each other. The Medical Intensive Care Unit (MICU) team is our honoree this year, for exceptional collaboration and clinical excellence in caring for some of the most critically ill patients in the hospital – and in the region. One of the most exemplary achievements of this unit is the culture of professional advancement: unit leaders mentor novice and experienced nurses, and encourage all of them to grow through our Professional Advancement Model, and the nurses take these opportunities to become leaders and better nurses. As you read on, you’ll see the evidence of this continuous advancement.

N Lisa Rowen, DNSc, RN, CENP, FAAN Chief Nurse Executive University of Maryland Medical System Senior Vice President of Patient Care Services & Chief Nursing Officer University of Maryland Medical Center Associate Professor University of Maryland School of Nursing

urse manager Kerry Sue Mueller, MBA, BSN, CCRN, says patient care in the MICU requires a nurse to be a jack of all trades and master of most. She should know: Kerry Sue was a MICU nurse for seven years and has been the manager for 13 years. She is proud of the MICU team and says, “They are energetic, compassionate, and dedicated to the patients and to the staff members who care for the patients.” Kerry Sue told the story of a long-term oncology patient who had become critically ill and was transferred from the UM Greenebaum Cancer Center (UMGCC) to the MICU. The family made the difficult decision to withdraw care. Susan Roy, DMin, BCC, director of pastoral care, shared with the MICU team that the oncology team was devastated to lose this patient whom they had cared for over the past years. The MICU nurses took care of the patient and family, and also opened their arms to the UMGCC team, inviting them to come and visit or stay with the patient and family. The MICU team, along with the GCC nurses and advanced practice nurses, physicians, and social workers, joined with 10 family members in prayer as the patient was removed from life support. “It was a special moment,” Kerry Sue said. “We weren’t just taking care of the patient and family and ourselves, we were also taking care of our colleagues from a different department.” The MICU team members are just as skilled and experienced in compassionate end-of-life care as they are in supportive care. Their patients are critically ill and the mortality ranges between 20% and 24%. Their expertise in end-of-life care is driven by a passion for providing closure for family members. Take the case of a 22-year-old patient in acute respiratory failure: The sending facility stated

Staff from the Medical Intensive Care Unit

the patient had no known family members, but a dedicated MICU social worker, Diana Vaughan, MSW, decided to try to track down the family. She contacted a friend of the patient through a police contact and was then able to locate the patient’s mom, who spoke no English. Via an interpreter, Diana arranged for and paid the cost of bus transportation from another city so the mom could visit the patient. The mom and patient had not spoken for quite a while and the mom was able to arrive just before the patient passed away. An interprofessional team composed of a nurse, social worker, chaplain, physician, respiratory therapist, and interpreter witnessed the reunion between the patient and mom, and the patient was able to approach the end of life with dignity, surrounded by compassion. continued on page 3.

Spring 2016

In This Issue 1

Lisa Rowen’s Rounds

Corporate Compliance

Annapolis 2016: Nurses Influence Legislation

Palliative Nursing at UMMC

Journal Club

UMMC’s Transitional Surgery Center

Nurses Week 2016

SICU’s Transition to Blended Provider Model

Spotlight on Pharmacy

Respiratory Care Services: Supporting our Profession Beyond UMMC

20 Core Measures 21 Safe Patient Handling & Mobility with the Mobile Practitioner Team 22

Toward a High Reliability Organization: UMMC Patient Safety Net

Cardiac Advance Life Support at UMMC

Achievements

Clinical Practice Update

Corporate Compliance Andrea Alvarez, Compliance Specialist – Education and Training Corporate Compliance and Business Ethics Group In each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) for News & Views. We are looking for new ways to reach out to employees to raise awareness of compliance issues. Please let us know what you think, or suggest topics by emailing compliance@umm.edu or aalvarez1@umm.edu. Compliance FAQ Q: My patient communicates using sign language and is requesting that his wife be allowed to interpret for him instead of using an outside agency interpreter. Is that allowed? A: Under certain conditions, yes. Our Patient NonDiscrimination policy number CC-1507 states: Family members or friends can act as interpreters only if the following conditions are met. 1. The hearing impaired patient and/or hearing impaired companion; a. Are informed of their right to free interpretation services; b. Have declined such services and signed a Waiver of Interpretation Services; and

c. Request that the family member or friend interpret. 2. The affiliate may still chose to have a medical sign language interpreter observe the interpretation session to ensure effective communication and delivery of safe care. 3. Generally, minors should never be allowed to interpret. The exception is in an emergency situation when a qualified medical sign language interpreter is not immediately available and the hearing impaired patient, support person(s) and/or the hearing impaired companion requests the minor to interpret until a medical sign language interpreter becomes available.

Find news&views online at http://umm.edu/professionals/nursing/newsletter and on the UMMC INSIDER at http://intra.umms.org/ummc/nursing/cppd/excellence/publications/news-and-views

Editor-in-Chief

Carolyn Guinn, MSN, RN Magnet Director, Clinical Practice and Professional Development Managing Editor

Susan Santos Carey, MS Manager, Operations Clinical Practice and Professional Development Editorial Board

Lisa Rowen, DNSc, RN, CENP, FAAN Chief Nurse Executive University of Maryland Medical System Senior Vice President of Patient Care Services & Chief Nursing Officer University of Maryland Medical Center Associate Professor University of Maryland School of Nursing Suzanne Leiter Executive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice and Professional Development, Neuroscience and Behavioral Health Chris Lindsley Director, Communication Services University of Maryland Medical System Anne Haddad Publications Editor University of Maryland Medical System

NEWS & VIEWS is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center. Scope of Publication The scope of NEWS & VIEWS is to provide clinical and

professional nursing and patient care services practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines

Send completed articles via e-mail to scarey@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 Summer 2016 Fall 2016 Winter 2017 Spring 2017

DUE DATE July 11, 2016 October 3, 2016 January 2, 2017 May 1, 2017

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 Lisa Rowen’s Rounds, continued from page 1. About the MICU The MICU is located on Weinberg 7 and is a 29-bed intensive care unit with all private rooms. The team cares for mainly transplant, oncology and respiratory-failure patients, and also a variety of issues such as sepsis, post-arrest, and chronic neurological illnesses. Approximately 110 nurses, eight patient care technicians, nine unit secretaries, one inventory specialist, one nurse manager, one administrative assistant, and a large team of attendings, critical care fellows, residents, and nurse practitioners “live” and work on the MICU, alongside interprofessional staff members from respiratory care, pastoral care, rehabilitation, care management, dietary, nutrition, social work, and pharmacy. Of the many nurses, 18 are senior clinical nurses, and about one-third of all MICU nurses are in graduate school pursuing master’s or doctoral degrees. They are a driven, professional, and committed group of nurses. Hannah Entwistle, BSN, RN, FCCS, CCRN, SCN I, and Kirsten Tomaschefsky, BSN, RN, CCRN, SCN I, completed an evidence-based performance improvement project to study “proning” patients in a hospital bed. Positioning patients in a prone position is frequently performed for respiratory failure patients because it allows for better ventilation of the lungs. The project began in a small way on the MICU, and then Hannah and Kirsten presented it at the Clinical Practice Council and also to the Critical Care Operations team. They shared the literature review they completed, collaborated with colleagues in physical therapy, developed the guidelines and protocol currently in the clinical practice manual, and are now educating staff on other ICUs. Hannah also is passionate about improving response time in cardiac arrest situations. She designed an educational simulation process that presents real-life scenarios on an acute unit and ICUs. This is called the Arrest Pager Training Pilot, and both acute and ICU nurses will complete simulation training as it is rolled out. Hannah has been on the MICU for about five years, working the first year as a patient care technician (PCT) while she was in nursing school. “There are so many opportunities on this unit, you can hit the ground running,” Hannah said. “I joined committees, networked with colleagues, and Kirsten and I were encouraged to work on the proning project, which set me up with skills for the Arrest Team project. There are endless opportunities here; my path for advancement has been easy and fun.” Most of the admissions arrive during night shift. The MICU averages about four admissions per night. “I love night shift!” said Hannah. “Night shift people are my kind of people. We depend on each other a lot. Our group is particularly awesome. We get a little more time with the patients and families.” Kirsten has also been on the unit for about five years, after working as a student nurse resident in the Greenebaum Cancer Center. She said, “I’m a night-shift nurse and we’re a close-knit group. We work really well together and always help each other whenever possible.” Kirsten, who is a member of the Staff Nurse Council, also joined the Professional Advancement Review Team.

She enjoys that both of these groups allow her to see what is going on outside of the MICU. Most recently, Kirsten was selected to be a unit-based safety clinician, which will allow interest in safety and performance improvement to flourish and skills to be further developed among the whole staff. Teamwork Across the Board Hannah described last fall, when the unit was a bit short-staffed, and a brand new nurse just off orientation received a critically ill patient with sickle cell anemia. The patient arrested after arriving and was placed on ECMO. The new nurse was swirling, trying to accomplish all of her tasks. Everyone just popped in and out of the room to do one or two things, helping all through the night. The new nurse did not have to ask for help; help was constantly right there at her side. Hannah continued, “We have a strong group of attendings and fellows. All of them are exceptionally smart. The attendings and fellows work well as a team with us. We feel respected and listened to, and they know when we come to them with something, it’s important.” When you ask MICU team members what they like most about the MICU, they frequently talk about the team. They often mention Melvin Dupree, MDiv, BCC, a night chaplain who serves MICU patients. Staff members appreciate that he always rounds and has a gentle demeanor and calming influence on patients, families, and staff. The respiratory therapists are also often mentioned by MICU staff as being great colleagues. continued on page 4.

Dear Gentlemen and Ladies on the UMMC staff, under whose care my mother was placed, Thank you so much for your dedication and care while treating my mother. Your work went far beyond just performing your duties. You’ve dispensed enormous grace to us during our family’s most difficult hours. . . . I did notice the compassion and love of the nurses and PCTs continuing to linger in my mom’s room: small, simple acts of kindness like adjusting the light just right for the current hour of the day or selecting the television channel that best matched the amount of stimulation that my mother needed at the moment. P.S. I do have a special message for Julia, the young nurse who had the misfortune of being assigned the task of starting the morphine drip at the beginning of the process to remove the ventilator from my mom. The tears in your eyes when you found out that we would be executing my mother’s advance directive did not go unnoticed . . . Thank you. It moved my heart that you cried for my mother. Portions of a letter from the grateful son of a former MICU patient.

Spring 2016

A Physician Colleague’s View of Teamwork in the MICU Carl Shanholtz, MD Professor of Medicine and Medical Director of the MICU and Respiratory Care Services

It is unclear what attracts us most to the MICU. It could be the challenging patients with the highest acuity and severity of illness seen in any ICU, anywhere. It could be the breadth and depth of interesting pathology and the fact that each time we are there we see something we haven’t seen before. It could be the multidisciplinary educational opportunities in an exciting interactive environment with some of the nation’s best and brightest physicians, nurse practitioners, nurses, respiratory therapists, pharmacists, dieticians, and physical therapists (Sorry if I left anyone out). These are professionals we see being educated in this living classroom every day. I think the best part of working in the MICU is being part of an enthusiastic and motivated team of the best staff, trying to do their best for those who deserve the best. This means that our mission of providing optimum care is internalized by each one of us. All have the chance to participate. All have the chance to lead. And no one is ever satisfied with the status quo – there is always more that can be improved.

A couple of specific examples stand out among many: Prone positioning as a treatment for the acute respiratory distress syndrome (ARDS) has long been used by some centers and is the subject of several promising clinical trials. Flipping a patient over to be mechanically ventilated face down is not an easy task at first and not without potential complications, such as accidental removal of catheters and tubes. Consequently, it was not a universally popular practice, and my early experience was not without problems. When the New England Journal of Medicine published a definitive clinical trial demonstrating the life-saving benefits of prone positioning in the sicker patients with ARDS, I had great trepidation in how I would get the nursing staff to buy in and how long it would take. But we are talking about the UMMC MICU nursing staff, and I should have known better. Hannah Entwistle, BSN, RN, FCCS, CCRN, and Kirsten Tomaschefsky, BSN, RN, CCRN, simply grabbed the ball and ran with it. They performed a literature search, formed a working group, called other centers who had published on prone positioning to review best practices, and within a few months had the protocol approved and the nursing staff trained. It is now one of the smoothest procedures we perform and we have had no adverse events related to the protocol. In another example, the MICU had the infamous distinction of being a contender for the highest hospitalacquired infection rates for bloodstream infections and urinary catheter infections (not only in the Medical Center but

in the nation), and out of frustration I had come to accept that this was an immutable fact of the medical critical care environment. I believed that there was nothing we could do to lower the rates. I should have believed in the MICU nurses. Maya Villegas, BSN, RN, chaired our unit’s Infection Control Committee, rallied the troops to adopt best practices, and consequently, through teamwork, we achieved sustainable hospital-acquired infection rates below the national average and some of the lowest in the Medical Center, going six months at a time between catheter-associated bloodstream infections. (Note: some may challenge this but I said “a time,” not “every time.”) This was another case of nurses grabbing the ball and running with it. Space does not allow me to cite all of the many examples where teamwork has accomplished spectacular goals. I haven’t even mentioned the advancing of our academic mission through multidisciplinary clinical research, for we have participated in both investigatorinitiated research as well as prestigious multicenter clinical trials, some of which have been published in prestigious medical journals such as the New England Journal of Medicine and the Journal of the American Medical Association (JAMA). As a clinic, a classroom, and a laboratory, the MICU fulfills – no, defines – the quadripartite mission of UMMS: healing, teaching, discovering, and caring. With all due respect to the Orioles, Ravens, and Blast, the best team in this town is the MICU.

Lisa Rowen’s Rounds, continued from page 3. Caring for Each Other Abigail Gatch, BSN, RN, CCRN, SCN I, known as Abby, and Cheryl Coale, BSN, RN, CCRN, SCN II, implemented The Pause Project, a performance improvement project that surveyed the MICU team members to determine the best way to do a hardstop pause after a patient death. A provider or clinician initiates a 30-second (or more) pause to honor the life of the patient and includes family members who are present. Abby said, “We want to honor the fact that this patient was a living, breathing human being in the world.” The team is working with the chaplains to initiate the pause on a consistent basis. The Pause Project was developed through the End-of-Life Committee, which focuses on the patients and their families, as well as the staff. Cheryl leads this committee, and explained that the staff members must care for each other, as well, during the

emotional process of caring for a dying patient. She explained the members are “conducting a survey of the nursing staff, respiratory therapists, advanced practice nurses, and physicians about how to better care for patients, families, and ourselves. We can’t give if we don’t have it to give.” The goal is that through improved care of the MICU themselves, the MICU team will be able to better care for their patients. The End-of-Life Committee works to create a memory for the family of patients who are dying. Donna Audia, RN, HN-BC, from Integrative Care, and chaplain Kathi Storey, MA, BCC, participate on this team. One collaboration led to having a music therapy intern who plays the guitar outside of the patient’s room. This is helpful to the family to cope with many phases of critical illness and, sometimes, the loss of their loved one. The focus on death and dying is handled with grace and extreme care by the team continued on page 5.

news &views Lisa Rowen’s Rounds, continued from page 4. members. Example after example of their work with end-of-life demonstrates their commitment to this part of the patient’s and family’s care. The MICU is well known for innovation. During the Epic Go-Live, Brian Le, BSN, RN, CNL, SCN I, independently created an Epic Quick Start Guide for MICU RN documentation. This educational tool was shared with his colleagues to bolster and support the Super Users and staff. Brian also created a tool entitled “What Night Shift Needs to do Before They Leave.” In this way, Brian helped ease the transition for the three Super Users and 19 MICU nurses at Go-Live, and the Quick Start tool was used repeatedly by nurses over the weeks that followed Go-Live. Danielle Evans, BSN, BA, RN, CCRN, SCN II, is leading a division-wide project to develop a plan to provide staff with feedback regarding incident reports, to encourage incident reporting, and to work towards the plan of being a “High Reliability Organization.” Using the AHRQ Safety Survey results, Danielle focused on two areas of deficit and created a performance improvement project with education for staff with separate reports for Kerry Sue and the staff, along with the rationale for the change. This project spans the entire medical/surgical/cardiac division. The MICU team is dedicated to professionalism and civility. The SCNs used a civility workshop created by Tina Cafeo, DNP, RN, CENP, vice president and associate chief nursing officer, and customized it for the MICU to train all of the staff. Over the course of three weeks, eight two-hour sessions were held. The staff rated the training highly. Team members believed the training served their goal to increase professional interactions with nurses and other disciplines.

networking, get to know others, and grow in experience after orientation. Nicole explained that the goal is to help novice MICU nurses learn about specific things they will encounter in the unit, like Blakemore tubes, code documentation, and code carts. Cynthia Roman, MS, OTR/L, CEAS, clinical specialist, occupational therapy, teaches the novice MICU nurses about safe patient handling and the use of lifts, and the team welcomes her expertise. Nicole started working in the MICU in 2006 as a unit secretary. She completed a bachelor of science degree in biology in 2007, graduated with an associate of arts degree in nursing in 2009, and a BSN in 2013. She is currently in school in the family nurse practitioner program. She is driven! At this point, you may think the MICU has a lot going on. Well, there’s more! They have many other unit-based shared governance committees. Highlights include:

Exemplary Professional Advancement If you were wondering how the MICU has so many SCNs, here’s how: Kerry Sue was committed to growing the group. She created the SCN Mentor Program. On a quarterly basis, Kerry Sue leads meetings for all nurses that focus on how to engage in the professional advancement process. The first half of the meeting is about documentation of accomplishments. The second half focuses on the SCN roles, and how the SCN should live, function and contribute to the MICU. At the conclusion of the meeting, Kerry Sue tells the team “Go home, think about it and let me know if you want to move forward with a mentor.” Every quarter, several people step forward to be mentored by current SCNs. The team knows that this role is not just a title; it carries responsibility to the unit, patients, and team members. Kerry Sue mentors the current SCN IIs, the SCN IIs mentor those who are SCN Is and those who are SCN Is mentor the CN IIs. The mentoring does not stop here. The Novice Nurse Support Group is unique to the MICU and focuses on nurses with two years or less of experience in the unit. Led by Nicole Hodski, BSN, RN, CCRN, SCN I, the group is open to new graduates and also experienced nurses with less than two years in the MICU. Kerry Sue brings all new orienteers into the MICU once a month to give them a peer group. At the bedside, preceptors mentor the novice nurses in the group. The novice nurses are expected to attend 12 sessions after orientation, to facilitate

Infection Control Efforts and Results Nimeet Kapoor, BSN, RN, CCRN, SCN I, also known as Nemo, is a second-degree nurse with his first degree in biochemistry. He loves being a nurse and spoke of the “many opportunities for advancement on the MICU.” Nemo is a member of the Infection Control Committee and helped lead a project in hand hygiene on the unit. He said that hand hygiene compliance initially ranged from 60% to 70%. The team consistently improved to reach 91%. In addition, CLABSI and CAUTI have significantly decreased. The unit had outperformed the CAUTI benchmark for the past four quarters (see Figure 1). To achieve this, the Infection Control Committee changed the signs on patient doors, used huddles and reinforced education with team members. Maya Villegas, BSN, RN, SCN I, leads the MICU Infection Control Committee. An active member of the committee, Danielle Evans, BSN, BA, RN, CCRN, SCN II, explained that in addition to staff re-education and consistent auditing, the MICU team has adopted infection control best practices “to where they are now second nature.” Kirsten added, “The culture has really changed. We need to have a really good reason for a patient to have a urinary catheter.” Kerry Sue explained the MICU team is also currently partnering with Infection Control colleagues and participating in a pilot to study chlorhexidine impregnated TegadermTM dressings to determine if this type of dressing will have a benefit

◗◗ the PCT/RN Committee, which focuses on performance improvement work between PCTs and nurses; ◗◗ the Unit Secretary Committee, which focuses on the redesigned role; ◗◗ the Charge Nurse Committee, which ensures appropriate and complete information is given to new charge nurses; ◗◗ the Infection Control Committee, which focuses on work that successfully decreased CLABSI and CAUTI; ◗◗ the Healthy Work Environment Committee; ◗◗ the Rewards and Retention Committee; ◗◗ the Patient Experience Committee; ◗◗ the Performance Improvement/Evidence-Based Practice Committee; and ◗◗ the End-of-life Committee.

continued on page 6.

Spring 2016

Lisa Rowen’s Rounds, continued from page 5. Medical Intensive Care Unit (MICU) Catheter Associated Urinary Tract Infections (CAUTI)

Foley Days

Rate per 1,000 Foley Days

# of CAUTI

CAUTI Rate

NHBN Pooled Mean

Foley Days

Figure 1

to further reduce central line infections. In addition, the MICU is participating in a study testing concentrations of chlorhexidine on the skin, either after bathing or via wipes, to determine if minimum concentrations of chlorhexidine on the skin after bathing has a different and potentially positive outcome than the use of chlorhexidine wipes. Nemo Kapoor and Minette Rilloraza, BSN, RN, CCRN, SCN I, together with the PCTs in the MICU, co-lead the PCT/RN Committee. Nemo said, “We need this committee. Nurses and PCTs both were confused about their roles and responsibilities. When Kerry Sue suggested forming the committee, Nemo and Minette jumped on board because they wanted to see more clearly defined roles and increased job satisfaction. They ask PCTs and nurses on the committee what they want to focus on each month. This group is empowered to make decisions. For example, the members created a report handoff tool for off-going PCTs to use with on-coming PCTs and a checklist for PCTs to use that outlines their duties, dependent on how many PCTs are working on any given shift. In this way, when only one PCT is working, the PCT and all of the nurses are aware of the expectations so the communication is clear and fair. Performance improvement (PI) is a continuous theme in the MICU. The unit-based PI Committee is led by Danielle Evans and Emmy Lou Cui, BSN, RN, CCRN, SCN I. The team worked on a Quiet Time initiative, performed a pre-survey and is currently collecting data from a post survey to study the initiative. Staff place posters on the patients’ doors showing photos of sleeping dogs and cats. All of the dogs and cats pictured are pets of the staff members, so not only is it caring (and cute!), it is also personal. The Quiet Time initiative was led by Abby Gatch, who is also working on another important PI project for the unit. She created the RL6 project, which focuses on educating the team about issues

and events that should be reported. As we move to an increasingly high reliability organization, it is important for team members to report not only significant events, but also near-misses. Abby and Michelle Long, RN, risk manager, presented the education to the staff and they’ve seen a big increase in reports – which is good! The Rewards and Retention Committee is led by Hannah Entwistle and Caitlyn Riebau, BSN, RN, CCRN, SCN I. They have raised money to support birthday recognition. The committee also created the Come See How Cool I Am board (see page 7), which serves as a “get to know you” tool for the MICU’s large team. Every month, they draw names of different staff members from a hat and these colleagues are interviewed and respond to 10 questions that continued on page 7.

news &views Lisa Rowen’s Rounds, continued from page 6. help others get to know them. The responses and the individual’s photograph are posted on the board, and it has helped people make friends with others who have similar interests. In addition to the Come See How Cool I Am board, the Rewards and Retention Committee has two others: A MICU Employee of the Quarter is selected to recognize those who “consistently shine.” A write-up and photograph are posted for all to see (below). The MICU Stars board (right) includes a packet of cut-out paper stars to use to write and post shoutouts and thanks Come See How Cool I Am to colleagues for help, support, and teamwork. This team knows how important it is to recognize each other for great teamwork and communication. The MICU team also focuses on supporting each other on the journey toward individual certification. Certification is promoted by Brian Le. A recognition board on the unit recognizes certified nurses and also provides education about earning certification. Currently, there are 34 certified nurses in the MICU. Great job, team! Marian Grant, DNP, CRNP, ACHPN, is a palliative care nurse practitioner who frequently consults on the MICU. Marian said, “This is my favorite unit. They see it all and care for every type of patient here. The MICU nurses know so much and care for a patient population with a higher mortality than other units. It can be hard because it’s the end of the road for many patients. The team is skilled and they have the best family meetings on this unit.” Kristin Brown, CRNP, agrees with Marian. Kristin works on the palliative care team and said “Palliative care on the MICU is excellent. The staff members are wonderful; they work well MICU Employee of the Quarter with us and have really great family meetings.” Starting his work in the MICU in 2011 as a nursing student, Chad Copeland, BSN, RN, CCRN, is currently in the DNP program. He said, “I’ve been here five years and it’s a great care team. Everyone takes care of each other.” Sami Schwartz, BSN, RN, worked on the MICU through supplemental staffing as a nursing student. She began working as a nurse on the unit in July, 2015. Sami said, “I had a great onboarding. I was prepared and ready to be on my own. We have so many people who serve as resources for questions and everyone is super helpful. The amount of time in orientation was just right and I loved the nurse residency and novice nurse classes.”

Keisha McElveen, MS, RN, CWON, is a wound nurse who spends about two or three hours per day on the MICU. She said, “The teamwork here is amazing. You can be in a patient’s room and look out the door and ask the staff for anything. The teamwork is tremendous!” Keisha shared that the nurses want to learn and are receptive and open to her education about wound care. “They have a staggering delivery of special beds here and I’m working with the team on a wound board to be more efficient,” Keisha said. While the patients have experienced a decreased CAUTI rate, Keisha said she has witnessed an increase in incontinence-associated dermatitis for some patients with no clinical indication for a urinary catheter. Adam Taylor, Jr., BSN, RN, worked in the Cardiac Surgery Stepdown Unit as a PCT while he was a student at Towson University. As his new graduate nurse orientation comes to an end, he reflected about the MICU. He said, “This unit is great, with excellent learning opportunities and rapport between staff. Everyone is really helpful. I found that school didn’t really prepare me to be a nurse but I’m learning that here. I’m learning time management!” Kerry Sue reminded me of one more big contribution made by the MICU nurses. She explained that one-half of the Dedicated Care Team is staffed by MICU nurses. This inpatient team comprises staff members from several units who were trained to care for patients with Ebola should any be admitted. In a time of uncertainty and fear, many of the MICU team stepped up in a compassionate and skillful way. For their care and compassion offered to their patients, families, and each MICU Stars other; for their amazing focus on safety and improvement in clinical outcomes and innovation; and for the culture of teamwork, communication, respect, and engagement, the MICU is well-deserving of the CNO Award for Team Excellence. Thank you to all members of this exceptional team for your spirit and incredible commitment to being one care team that is focused on excellence in every aspect!

Spring 2016

Annapolis 2016: Nurses Influence Legislation Tara Carlson, MS, RN, Manager, Business Development and Center for Injury Prevention and Policy, R Adams Cowley Shock Trauma Center and Karen Doyle, MBA, MS, RN, NEA-BC, FAAN, Senior Vice President, Nursing and Operations, R Adams Cowley Shock Trauma Center and Care Management

For years, nurses in the Trauma Resuscitation Unit (TRU) and emergency departments have been subpoenaed by attorneys to testify to their competence to draw blood from impaired patients. As a background to this issue, in any given quarter, approximately 30-40 TRU nurses are issued subpoenas to testify to their competence to perform blood collection to determine blood alcohol levels. Drawing blood is a basic skill within the scope of practice of all licensed nurses in the state of Maryland. Having the nurse attest to their level of competence to perform this fundamental skill is wasteful to both the judiciary and health care system. Issuing a subpoena removes that nurse from the work schedule and requires the nurse be replaced on that shift. Frequently, cases are resolved at the last moment when defendants plead out making the nurse’s testimony unnecessary, despite the fact that the nurse has lost a shift and an effort has been made to reschedule. Moreover, nurses are being forced to travel across the state on some occasions because they happen to provide their health care services at the R Adams Cowley Shock Trauma Center, where trauma victims from all corners of Maryland are transported after the accidents occur. On an annual basis, this costs the Medical Center approximately $218,400. As the system is currently configured, this is a wasteful process. Valuable time, effort and resources are continually diverted from patient care to no practical, useful end. Recognizing the burden this places on our nursing staff and on the Medical Center, our colleague Sandra Benzer, Esq., associate counsel, UMMS, reached out to the Maryland State’s Attorneys Association seeking a solution. The Association, in turn, joined forces with Senator Robert Cassilly and Delegate Geraldine Valentino-Smith to draft legislation eliminating the need for nurses to testify to this basic core competency. Ultimately, two bills were introduced during the 2016 session of the Maryland General Assembly: House Bill 773 (sponsored by Delegate Valentino-Smith) and Senate Bill 1008 (sponsored by Senator Cassilly) Drunk and Drugged Driving – Evidence of Blood Test. The bills provided that a nurse who performs a blood draw does not have to testify in court if a law enforcement officer who witnesses the blood draw attests to the fact that the blood was drawn by a qualified individual and that proper procedures were followed. Karen Doyle, MBA, MS, RN, NEA-BC, FAAN, representatives from the Maryland Nurses Association and the Maryland State Police, and several State’s Attorneys provided strong support for the bills during public hearings in both the Senate and the House of Delegates. Donna Jacobs, senior vice president, government, regulatory and community affairs, UMMS, and Kristin Jones Bryce, vice president, external affairs, UMMS, advocated for the bills throughout the legislative session and

Delegate Kathleen Dumais was instrumental in garnering support from her colleagues. The House version of the bill was ultimately passed by both the House Judiciary Committee, led by Chairman Joseph Vallario, and the Senate Judicial Proceedings Committee, led by Chairman Bobby Zirkin. In addition, House Bill 773 received unanimous votes in the House and Senate chambers. As of this writing, Governor Hogan is expected to sign the bill in May and the resulting law will take effect October 1, 2016. Another example of the Trauma nurse’s influence can be seen in the role that Tara Carlson, MS, holds as chair of TraumaNet, a statewide advocacy group for the Maryland trauma system. Carlson testified in support of legislation for stricter ignition interlock requirements in both the House and Senate. Other trauma centers were active and provided both oral and written testimony. House Bill 1342 and Senate Bill 945 Drunk Driving Reduction Act (Noah’s Law) increased the suspension periods for the driver’s license of a person who is convicted of offenses relating to driving under the influence and driving while impaired and increased the categories of offenses for which participation in an ignition interlock program is mandatory. The Senate version of the bill was passed during the 2016 legislative session and is expected (as of this writing) to be signed by Governor Hogan in May. The new law will take effect October 1, 2016. Nurses make a substantial difference in the political process in a variety of ways. We can impact our profession by paying attention to legislation that is introduced and by contacting our elected representatives to voice our opinions, whether they are positive or negative. We must also pay attention to laws that are current and the impact they have on our work environment. Continuously keeping oneself informed and taking a position on a topic is the first step in making a difference. Taking that next step takes courage and fortitude but remember the old adage that there is strength in numbers. Those who make laws have power, but so do we. Let’s not forget that we as nurses are the most trusted profession in the country. Our voice matters. At UMMC, we have made great strides in recent years in terms of political activism. What we do in the political arena potentially impacts all of health care. Every year from October to April, a group of interested health care providers gather together to discuss the upcoming legislative session and to determine if there is legislation that they want to influence. If you are interested in furthering your understanding of the legislative process and would like to take a more active role, feel free to reach out to Tara Carlson (tcarlson@umm.edu), Karen Doyle (kdoyle@umm.edu) or Claudia Handley (chandley2@umm.edu).

news &views Palliative Nursing at UMMC Steven R. Eveland, MBA, RN, CHPN

Palliative nursing is one of the many areas of specialty practice at UMMC. Nurses are uniquely positioned to support and provide palliative care. According to Betty Ferrell, PhD, RN, FPCN, FAAN, a leader in the field of palliative care, “From initial diagnosis through endof-life, nurses spend more time with seriously ill patients and their families than any other health care provider.” (ACCN, 2016) Nurses have always been concerned with palliative issues – quality, suffering, and family-centered care – and those issues are now part of the broader discussion evolving in health care today. Every nurse at UMMC has the opportunity to provide generalist palliative care when they offer expert symptom assessment, when they recognize existential distress and provide comfort or a pastoral referral, and when they support patients and families making difficult decisions. Generalist palliative care is the basic level of palliative care knowledge of which all nurses (and other providers) should have a general understanding. Specialist palliative care is provided by those with advanced knowledge and skills, the result of further education and training (Quill, 2013). These skills speak directly to issues of quality for our patients and the purpose of palliative work. Evolving from the modern hospice movement, palliative care is now a recognized medical specialty for which physician providers must be board certified. Balfour Mont, a Canadian oncologic surgeon, originally defined palliative care as “anticipating, preventing, and treating the suffering patients experience in the last phase of a life-threatening disease or condition” (Dunn, 2009). While palliative care still encompasses those goals, the scope has expanded to include aggressive symptom management and supported decision-making. Without effective management of symptoms, the patient is unable to explore important issues and interact with family and friends. Researchers have also shown that palliative services increase satisfaction and decrease costs associated with end-of-life care (May, 2015). In the last ten years, the field of palliative medicine has grown dramatically, and with that, the opportunities and responsibilities of nurses have increased. In the 2010 Institute of Medicine (IOM) report on The Future of Nursing, nurses were identified as ‘ideal providers’ of palliative care. The authors noted, “Palliative care is a model that is consistent with basic nursing values, which include caring for patients and their families regardless of their age, culture, socioeconomic status, or diagnoses, and engaging in caring relationships that transcend time, location, and circumstances” (RWJF, 2012). The 2014 IOM report, Dying in America, also highlighted the need for additional nursing education about palliative issues (IOM, 2014). Nurses can receive education and training in palliative care through a variety of sources, including masters programs, fellowships, and subsequent certifications offered by the Hospice and Palliative Nurses Association.

At UMMC, embracing the concept of palliative care dates to 1999 when the ethics committee developed clinical practice guidelines to help manage symptoms associated with life-limiting illness. A related program was piloted in the Medical Intensive Care Unit in 2000. Interdisciplinary work continued toward the development of a palliative and supportive care program in 2002, which was the result of a collaboration between nursing, social work, pastoral care, and medicine. Carla S. Alexander, MD, was the first medical director of palliative care at UMMC, with program administration under the Department of Social Work. The program is now administered by Patient Care Services and led by Heather Mannuel, MD, MBA, interim medical director for the Palliative Medicine Service and assistant professor of medicine, working with Ila Mulasi, MD, assistant professor of family and community medicine. The Service is staffed by nurses, nurse practitioners, physicians, and a pharmacist. The Palliative Medicine Service is a consult service and supports primary teams in managing symptoms and addressing goals of care issues with patients and families, as well as providing end-of-life care. Typical symptoms include pain, shortness of breath, constipation, anxiety, and many others. Everyone on the team addresses issues around meaning, quality, and suffering, and supports patients throughout the hospital and in the outpatient setting. In 2015, the Palliative Medicine Service received almost 1,000 consults representing most medical services. Looking forward, the need for palliative services will continue to grow with ongoing opportunities for enhanced patient care, as well as training and education for nurses and other health care professionals. The Palliative Medicine Service will start an outpatient clinic in cooperation with the Greenebaum Comprehensive Cancer Center later in 2016. The next End-of-Life Nursing Education Consortium training will be offered in September of 2016. In concert with other disciplines, the Palliative Medicine Service is also developing a bedside patient care program to help focus attention on the unique needs of patients and their families at the end of life. As of January 2016, Maryland House Bill 581 requires all hospitals in Maryland with over 50 beds to have palliative care available for their patients (Gibbs, 2015). Most recently, the American Association of Colleges of Nursing has also endorsed a new set of competencies for undergraduate nursing education to address end-of-life care and help prepare the next generation of nurse leaders as our population ages and we live longer with advanced, and often life-limiting, diseases. References American Association of Colleges of Nursing. (2016). AACN takes action to enhance end-of-life nursing care. [Press Release]. Retrieved from http://www.aacn.nche.edu/ news/articles/2016/elnec Dunn, Geoffrey P., et al. (2009). Surgical palliative care: a resident’s guide. American College of Surgeons. Retrieved from https://www.facs.org/~/media/files/education/ palliativecare/surgicalpalliativecareresidents.ashx Gibbs, K., et al. (2015). An assessment of hospital-based palliative care in Maryland: infrastructure, barriers, and opportunities. Journal of Pain and Symptom Management, 49, 6, p. 1102-1108. doi: 10.1016/j.jpainsymman.2014.12.004. Epub 2015 Jan 30. Institute of Medicine. (2014). Dying in America: Improving quality and honoring individual preferences near the end of life. Key findings and recommendations. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20 Files/2014/EOL/Key%20Findings%20and%20Recommendations.pdf May, Peter, et al. (2015). Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger costsaving effect Journal of Clinical Oncology, 33, #25, p. 2745-2752. Quill, T., et al. (2013). Generalist plus specialist palliative care – creating a more sustainable model. New England Journal of Medicine. 368, 13, p. 1173-1175. Robert Wood Johnson Foundation (2012). Advocates call on nurses to take leading role in palliative care. Retrieved from http://www.rwjf.org/en/library/articles-andnews/2012/09/advocates-call-on-nurses-to-take-leading-role-in-palliative-care.html

Spring 2016

Journal Club

Simulation-Based Mastery Learning Improves Central Line Maintenance Skills of ICU Nurses Authors: Jeffrey H. Barsuk, MD, MS; Elaine R. Cohen, M.Ed.; Anessa Mikolajczak, BSN, RN; Stephanie Seburn, BSN, RN; Maureen Slade, MS, RN; Diane B. Wayne, MD Barbara Bosah, BSN, RN, PCCN, Senior Clinical Nurse I from the Surgical/Thoracic Intermediate Care Unit (SIMC/TIMC) on Gudelsky 9 East, facilitated the March Journal Club for the article “Simulation-Based Mastery Learning Improves Central Line Maintenance Skills of ICU Nurses” (Barsuk et al., 2015).

Hospital-acquired infections (HAIs) affect millions of patients each year. These infections are costly to individuals and health care systems. They can significantly increase the morbidity and mortality of patients. In the United States, hospitalized patients experience 250,000 central line-associated bloodstream infections (CLABSIs) annually. This results in 62,000 deaths at a cost of $6,000 per case.

Several studies have shown that CLABSIs are preventable through the use of various clinical procedures, such as central line bundles, skills checklists, antibiotic/antiseptic impregnated catheters, port protectors, neutral displacement needleless connectors, chlorohexidine dressings/baths, and the use of ultrasound guided insertion of catheters (Harnage, 2012; O’Grady, Alexander, & Burns, 2011). Several studies have shown that simulation is a superior method to educate health care providers on a broad range of clinical skills. Mastery learning is an intense form of competency-based learning. Simulation-Based Mastery Learning (SBML) trainees are required to achieve competency in a simulated setting prior to performing clinical skills in actual patient care.

The purpose of the study presented in this article was to first evaluate the variability in central line maintenance skills among ICU nurses; and, second, to design and implement a SBML curriculum for central line maintenance and measure its effects as an educational intervention.

The pre-test – post-test study was conducted at the Northwestern Memorial Hospital (NMH), an 897-bed academic, urban, tertiary care

facility located in Chicago, Illinois. The Cardiothoracic ICU (CTICU) is one of five ICUs at NMH and was selected by nursing leadership for this study because of a recent increase in CLABSI rates. To examine variability in central line maintenance skills, a checklist was developed to assess five different aspects of central line maintenance tasks. The checklist included recommendations from the Infusion Nurses Society and Centers for Disease Control and Prevention for evidence-based central line maintenance. Eight ICU nurse educators developed the checklist using a modified Delphi technique, step-by-step guidelines, and dichotomized scoring. The checklist was piloted before general study use. The five aspects of central line maintenance examined with the checklist include medication administration, injection cap (needleless connector) changes, tubing changes, blood draws, and dressing changes. All participants underwent a simulated baseline assessment (pre-test) of central line maintenance skills using the checklist. They also watched a video and lecture on evidence-based central line maintenance techniques. Those who met or exceeded a minimum passing score (MPS) for a specific pre-test were

not required to complete additional training for that task. Failure to meet the MPS required an additional one hour of instructor-directed practice with feedback for each skill for which the MPS was not attained. Posttraining, nurses completed another simulated skills assessment (post-test). Study participants were assessed using Simulab’s CenralLineMan (Seattle, Washington) and Gaumard’s PeterPICC (Waco, Texas). The assessments were conducted by nurse raters who were trained in a four-hour train-the-trainer session. The checklist used to rate nurses’ skills included behaviors that if not performed, resulted in immediate failure. These included failure to perform hand hygiene, failure to scrub the injection cap with chlorohexidine or alcohol solution for at least 15 seconds and allowing it to dry for at least 15 seconds, and any violation of the sterile technique. If any of these occurred, the remaining items on the checklist were marked incorrect, and the simulation was stopped. Sixty-one nurses participated in the study. Of those, 12 participated in the pilot testing of the curriculum and 49 nurses completed the SBML curriculum intervention. The demographic data of each nurse was obtained, including age, sex, level of education, and years of total nursing experience. The nurses had a mean of 10 years of clinical experience, almost exclusively in the ICU. The number of nurses passing the pre-test tasks ranged from 40% for the dressing change task to 90% for changing the tubing. Twenty-two percent (11 nurses) of the nurses passed all five central line maintenance pre-test tasks and were not required to complete additional training. At baseline, the mean overall score was 77% (56/72 [SD, 19.36] items correct). At post-test, scores for each task improved significantly. Medication administration scores improved from a median of 46.2% (interquartile range [IQR], 19.2%-46.2%) items correct at continued on page 11.

news &views Journal Club,

continued from page 10.

Group Discussion

At the University of Maryland Medical Center (UMMC), several measures are in place to optimize central line maintenance. These appear to be effective as CLABSI rates are trending downward. The research article “Simulation-Based Mastery Learning Improves Central Line Maintenance Skills of ICU Nurses” may provide an opportunity to identify areas for further improvement with education and training on central line care. A standardized and systematic process of education may promote further reduction in UMMC’s CLABSI rates.

pre-test to 100% (IQR, 100.0-100.0) at post-test (p <.001). Injection cap change scores improved from a median of 73.1% (IQR, 46.2%-82.7%) to a median of 100% (IQR, 92.3%-100.0%; p < .001); tubing change from a median of 0.0% (IQR, 0.0%-64.3%) to a median of 100.0% (IQR, 50.0%-100.0%; p= .07); blood draw from a median of 30.4% (IQR, 17.39%-50.0%) to a median of 100.0% (IQR, 93.5%-100.0%; p < .001); and dressing change from a median of 43.8% (IQR, 37.5%-81.3%) to a median of 100.0% (IQR, 100.0%100.0%; p <.001). Six of 35 nurses (16%) did not meet the MPS in one or more skills at post-test and required additional training of less than one hour to achieve the MPS. The total years of nursing had a significant negative correlation with the overall baseline performance (r= -0.30, p=.04). For individual task performance, total years in nursing and total years in ICU nursing had significant, negative correlations with only medication administration pre-test performance (r= -0.423, p= .003; r= - 0.422, p= .003, respectively).

In this study sample, a majority of experienced ICU nurses were unable to competently or consistently perform central line maintenance tasks. These findings are consistent with previous research which demonstrated a variability of nurses’ ICU skills. The study results reinforce the importance of structured education and competency assessments to achieve patient safety goals. Despite years of clinical experience, ICU nurses significantly improved their performance after SBML. The authors addressed a few study limitations. They acknowledged that the study was performed at only one institution with a relatively small sample size. In addition, simulation models were used in both education and testing, potentially confounding the improvement in post-test scores. Post-testing occurred immediately after training, potentially enhancing recall. These limitations do not diminish the impact SBML had on nurses’ clinical skills. In this study, the authors did not link improved central line maintenance skills with reduced CLABSI rates. However, the authors are planning to evaluate outcomes in a future study.

Different training options discussed: ◗◗ The use of Super Users on each unit to be trained to assess central line sites every shift or day; ◗◗ Possibility of training patient care technicians; ◗◗ Possibility of implementing SBML at UMMC; ◗◗ Possibility of central line nurse to change dressings on all patients with central lines with particular attention given to patients with total parenteral nutrition; and ◗◗ Concluded that some patients may need dressings changed multiple times in a shift. So staff nurses need to be competent in central line dressing cares. References Baruk, J.H. et al, (2015). Simulation-Based Master learning Improves Central Line Maintenance Skills of ICU Nurses. Journal of Nursing Administration, 45(10), 511-517. Harnage, S. (2012). Seven years of zero central-lineassociated blood-stream infection. British Journal of Nursing. 21:S6, S8, S10-S12. O’Grady N., Alexander, M., Burns, L. (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases, 52:e162-e193.

Spring 2016

AMBULATORY SERVICES

The University of Maryland Medical Center’s Transitional Surgery Center (TSC) Priya K. Nair, MS, RN, Nurse Manager, Transitional Surgery Center (TSC), Ambulatory Services

The Health Services Cost Review Commission (HSCRC) defines preventable, avoidable, unplanned admission (PAU) as “hospital care that is unplanned and can be prevented through improved care, care coordination, or effective community-based care, or care cost increases that result from a potentially preventable complication occurring in a hospital.” In February 2015, the TSC at UMMC was established as a collaborative between surgical nurse practitioners (NPs) and nursing leadership and staff nurses in the Surgery Subspecialty clinic. An evidence-based process improvement project was undertaken and aimed at improving care and decreasing emergency department (ED) visits and hospital readmissions among the post-operative population by improving access. Goals of the program: ◗◗ Identify clinical issues on a proactive basis with the use of telephone nursing triage; ◗◗ Improve patient access with urgent clinic appointments; ◗◗ Decrease post-operative ED visits and subsequent readmission; ◗◗ Establish a program to monitor post-operative home-care/self-management to avoid readmission; and ◗◗ Improve patient satisfaction.

Figure 1: TSC Patient Communication Workflow

The TSC received notification on October 29, 2015 that the HSCRC approved TSC as a new hospital-regulated clinic. The TSC program is housed in the regulated Surgery Subspecialty Clinic on the ground floor of the North Hospital. Current specialty practices included are surgical oncology, vascular, urology, and general surgery, in addition to the Digestive Health Center on 8 North. Volume assessments demonstrated that the TSC would initially see about 165 patients per month, with a future projection of 206 patients per month. Initial staffing was determined after review of volumes and gaps in transition of care in the surgical population. Current staffing includes two full-time nurses in the Subspecialty Clinic and a third full-time nurse focusing on the PAU efforts. The nurses provide telephone triage to post-surgical patients, as well as clinical support for infrequent clinic visits for this population (50% clinical time of two nurses). Additionally, these nurses staff the clinic and deliver nursing care for the population of urology patients from both a procedural and clinic visit perspective (50% clinical time of two nurses). A third nurse is dedicated to patient outreach and to the transitional surgery program. Communication roadmap and workflows outlining TSC processes were created (see Figure 1). The TSC is a collaborative nurse-driven program and is managed within Ambulatory Services. Operational management of the site falls under the leadership of Cathy Widmer, MSN, RN, director, and Priya Nair, MS, RN, nurse manager. Carmel McComiskey, DNP, CRNP, FAANP, FAAN, directs and oversees nurse practitioner staffing and responsibilities. Sandy Regula, the faculty practice liaison, serves as the main contact for questions/ issues regarding operations and workflows from the faculty continued on page 13.

news &views UMMC’s Traditional Surgery Center (TSC), continued from page 12.

Readmission Rate TSC

Baseline CY13 Baseline CY14 Jan – June 2015 July – Oct 2015

Service (# enrolled in TSC) timeframe in TSC

CY13 Baseline

CY14 Baseline

January – June 2015

July – October 2015

Surgical Oncology (n=339) Feb 2015 - present

19.5%

18.6%

16.6%

15%

Vascular (n=412) Mar 2015 - present

20.4%

22.7 %

20.2 %

17.4 %

General Surgery (n=118) Feb 2015 - Aug 2015 Dec 2015 - present

16.4%

15.3 %

12.1 %

13%

Figure 2

Transitional Surgery Center Team members: Left to right: Priya Nair, MS, RN; Gloria Fisher, BSN, RN; Maria Azenith Quinamague, BSN, RN, and Jessica Gayle, RN

practices. Jennifer Zeller, CRNP, works as lead NP who supports the team with provider engagement. With a coordinated and proactive approach to surgical discharges, Ambulatory Services will play a critical role in preventing PAUs. See the outcome of these efforts by the TSC team in Figure 2. The members of the team include TSC nurses, Gloria Fisher, BSN, RN; Jessica Gayle, RN; Maria Azenith Quinamague, BSN, RN; and service line NPs and PAs, Jennifer Zeller, CRNP; Sarah Rosenberger, CRNP; and Erin Hanlon, PA. They provide department-specific support with tools, resources and clinic visit capability to teams in cardiac surgery, bariatric surgery, and thoracic surgery. The care coordinator in those departments follows up with the patient. TSC provides tools, resources, and monitors the data for the progress of the team’s work. The TSC continues to grow and is working on providing service to more surgical patients. Recently the TSC team had an abstract accepted for the 2016 Magnet conference and they will be presenting it in a podium presentation in October in Orlando, Florida.

Spring 2016

NURSES WEEK 2016

Kick-off Event – Trends in Nursing Practice Conference 2016 – “Death and Dying: Compassionate Care and Clinical Excellence at End-of-Life” — May 6, 2016 The purpose of the conference was to discuss evidence-based practices of end-of-life care and the essential and critical role of the health care provider. The conference focused on how the health care provider can assess, address, and meet the many complicated needs of the patient and family at end of life. Carol Taylor, PhD, RN, of Georgetown University was the keynote speaker. Nursing Staff and Nursing Support Breakfast – May 6, 2016 Over 1,200 nurses and support staff attended the breakfast where they were greeted by Dr. Rowen and served by senior hospital leadership. The waffle bar was again popular with staff and they were also able to enjoy, eggs, bacon, sausage, hash brown potatoes, muffins, and yogurt. Coffee Bar – May 7, 2016 Weekend nursing and support staff were treated to a continental breakfast (bagels, pastries, and yogurt parfaits) catered by Panera Bread and served by senior leadership from Adult Psychiatry. Support Staff Salute Day and Team Celebrations – May 9-12, 2016 Units celebrated and recognized their support staff and their entire nursing team in various ways, including breakfasts, lunches, and awards. Many units created their own awards and superlatives for their staff. Superlatives such as “Best Overhead Voice,” “Most Likely to Make You Laugh,” and “Biggest Coffee Drinker” were presented in the Adult Emergency department.

news &views

UMMC Nursing: Where Extraordinary is Ordinary

Clinical Practice Summit – May 10 and May 11, 2016 Over 40 abstracts were submitted this year using an online submission process. Thirty-seven posters were presented during rounds, with such topics as stem cell infusion, ondemand patient education, and minimizing sleep deprivation in night shift nurses. For the first time, the posters were judged by colleagues from the University of Maryland School of Nursing for a “best of” in each of the categories (research, evidence-based practice, and process improvement). Votes were also collected from participants and visitors to the Summit for a People’s Choice award. Winners will be announced in the next issue of News & Views. Nursing Grand Rounds – May 11, 2016 Topic – Nursing: The Art of the Science Speaker – Lisa Rowen, DNSc, RN, CENP, FAAN

Thanks to all those in Patient Care Services who submitted posters for the Summit! Clinical Practice Summit Posters Best Evidence-Based Practice poster TITLE OF PROJECT: A Bedside Nursing Checklist for

Therapeutic Hypothermia UNIT: Cardiac Intensive Care AUTHORS: Christa Stultz, BSN, RN and Tara Daniels, BSN, RN

Best Process Improvement poster

Chief Nurse Executive University of Maryland Medical System

TITLE OF PROJECT: Compliance of Daily Weights in

Senior Vice President of Patient Care Services and Chief Nursing Officer University of Maryland Medical Center

UNIT: Surgical Intermediate Care Unit/Thoracic Intermediate Care AUTHORS: Barbara Bosah, BSN, RN, PCCN, SCNI;

Associate Professor University of Maryland School of Nursing

Nursing Excellence Awards – May 12, 2016 Special Achievement nominees and award recipients were recognized during a ceremony hosted by Dr. Rowen. New award categories were presented this year including “Art of Caring, Personifies Professionalism, “Quality”, “Safety,” and UMMC’s first DAISY recipient was honored.

Preventing Post-Operative Complications

Lindsay Riesett, RN, CNII; Genevieve Vidal, BSN, RN, PCCN, CNII; Joseph Diloy, BSN, RN, CNII; Whitney Kimbrugh, BSN, RN, CNII; Mary Ann Hinahon, BSN, RN, CNII; Stella Aroh, RN, CNII; and Robert Burdette, BSN, RN, CNII Best Research poster TITLE OF PROJECT: The Relationship of Compassion,

Fatigue, Burnout, and Unprofessional Behavior in a Level I Urban Trauma Center UNIT: STC Operating Room AUTHORS: Kendall Gelston, BSN, RN, CNOR; Michelle Bardakh, BSN, RN; Paul Thurman, MS, ACNPC, CCNS, CCRN; and Kathryn VonRueden, MS, CNS-BC, FCCM People’s Choice award for best poster TITLE OF PROJECT: Perioperative Stroke Screening PI Project UNIT: Adult Post Anesthesia Care (PACU) AUTHORS: Julie E. Busseau, BSN, RN, CPAN;

Kristin Seidl, PhD, RN; Beatrice Hazzard, MS, RN, CPAN; Michael S. Phipps, MD, MHS; Jacqueline Y. Dash, MJ, BSN, QIC; and Karen Yarbrough, MS, CRNP

Spring 2016

ADVANCED PRACTICE NURSING

The Surgical Intensive Care Unit’s Transition to a Blended Provider Model: Advanced Practice Providers and PGY-2 Residents Dawn M. Silverman, MS, AG-ACNP, Clinical Nurse Practitioner and Physician Assistant Program Manager, Surgical Intensive Care Unit

Background

The Surgical Intensive Care Unit (SICU) provides care to a wide range of postoperative patients, as a diverse group of surgical services (e.g., emergency general surgery, vascular, solid organ transplant, thoracic, surgical oncology, and oral maxillofacial) refer their patients to the SICU. For more than two decades the SICU had functioned as a closed 19-bed intensive care unit on Gudelsky 4W. A single intensivist (either from the Department of Anesthesiology or Surgery) led a team of two surgical and two anesthesia residents, as well as a critical care fellow. Each resident took an assignment of four to six patients and presented their patients to the intensivist on morning rounds. Each day, one resident would take 24-hour call to cover overnight with the supervision of a fellow. The SICU was ahead of the curve when it came to being a closed surgical ICU. SICU providers coordinate all multidisciplinary care with the surgical services, who do not place orders on their patients while they are in the SICU. All information, therefore, is distilled through the SICU team, which implements the plan of care. In February 2013, the Society of Critical Care Medicine Taskforce on ICU Staffing released a statement regarding intensivist/patient ratios. Several of the taskforce’s findings directly related to the SICU operational model, which are as follows: ◗◗ Proper staffing impacts patient care; ◗◗ Large caseloads should not preclude rounding in a timely fashion; ◗◗ Institutions should regularly assess their staffing; and ◗◗ Intensivist/patient ratios greater than 1:14 negatively impact education and patient care (Ward et al., 2013). The SICU’s intensivist-to-patient ratio exceeded the recommendation of the taskforce and morning rounds often extended past noon, particularly on Thursdays when the surgical residents attend Grand Rounds and other required educational activities in the morning. Transition In June 2013 the SICU relocated to a larger 24-bed unit in the new, state of the art Critical Care/Shock Trauma Tower. This move allowed the SICU to have direct access to the surgical suites via an adjoining elevator. As the SICU rarely had a vacant bed in the previous unit, the expansion improved throughput of critically ill post-surgical patients. The additional rooms increased the SICU’s potential census by approximately 25%, which necessitated a reconsideration of the existing provider staffing model and ratios. The SICU physician and nursing leadership teams collaborated to design a staffing model that would adhere to the taskforce recommendations and the Accreditation Council for Graduate Medical Education’s (ACGME) work hour restrictions for residents (no more than work 80 hours in a week and no more than 24

hours of continuous duty) (Accreditation Council, 2011). Cindy Dove, MS, RN, SICU nurse manager, and Meredith Huffines, MS, BA, RN, SCN II, worked closely with advanced practice providers (APP) leadership to integrate the model into the unit culture. Additionally, they designed surveys to measure nurse satisfaction related to the model and collaboratively devised action plans for improvements. The SICU transitioned to a blended provider model consisting of resident physicians, nurse practitioners, and physician assistants. Accordingly, APPs were hired, oriented, and trained to provide post-surgical critical care management. The new model divided the unit into two teams: team A (covering beds 1-12) and team B (covering beds 13-24). The SICU adopted a two-intensivist model, with an anesthesia intensivist leading one team and a surgical intensivist leading the other. The addition of a second attending brought the intensivist-to-patient ratio to 1:12. Each team conducts daily rounds with an intensivist, a resident, continued on page 17

Blended Provider Model for 24-bed SICU Resident Physicians, Nurse Practitioners, and Physician Assistants provide post-surgical critical care management.

Team A covers 12 beds

Team B covers 12 beds

Two-intensivist model (anesthesia and surgery) brings intensivist-to-patient ratio to 1:12.

news &views SICU Transition to Blended Provider Model, continued from page 16. and an APP. A critical care fellow rounds with the team with the higher acuity on any given day. Overnight, each team is covered by either a resident (on 24-hour call) or an APP, and a critical care fellow. Challenges There have been several challenges with the staffing model. First, transitioning to a blended model does not occur overnight. It takes years to recruit and onboard a novice team to a new ICU environment. The transition began with three nurse practitioners and eventually expanded to seven advanced practice providers. Second, the nurse practitioner/physician assistant (NP/PA) position requires a high level of responsibility; e.g., rotating day and night shifts, 365 days a year; competence in invasive procedures, such as central line placement; and the expertise required to handle six patients, all of whom must be assessed and presented with a comprehensive plan in early morning rounds. The candidates selected had to be proactive and dynamic clinicians with good communication skills who could synthesize information and act quickly. Third, the patients are critically ill and the surgical teams, who leave their patient in the care of the SICU providers, expect expert care and excellent communication. Other challenges in the model relate to the differences in the work hour expectations between the APPs and that of the residents. Residents are expected to work no more than 80 hours a week to maximize their learning opportunities. An APP is hired to work 80 hours bi-weekly. Designing a schedule that achieves parity among teams (each team has a resident and an APP working 12-hour shifts daily) does not easily allow for the demands of residency hours nor the limitations of an APP schedule. The team has struggled to configure an APP schedule that permits true continuity of care when seven APPs are working three to four shifts per week. Typically, APPs work consecutive days on the same team for day shift. Because the team A and team B residents alternate night coverage, an APP working consecutive nights will need to alternate coverage of the beds on the A and B sides. Accurate handoff for each shift is essential when the patient may have several different APPs managing care in the course of a week. Designing and implementing tools to document the daily events, consults, and outstanding issues for each patient has been critical to optimizing patient care and safety. Strengths The demand for ICU beds has outpaced the supply of intensivists for more than three decades. Integration of APPs in the ICU has helped to mitigate this workforce shortage (Ward et al., 2012). The increased presence of APPs in the ICU may reflect a paradigm shift for academic medical centers; however, it does not reflect a compromise in patient care. Garcia et al. found that unit-based APPs improve the patient care environment through increased compliance with clinical practice guidelines, regular review of patient’s active order for correctness, involvement in education and teaching, provision of monthly orientation for rotating residents, and involvement in

performance improvement processes (Garcia et al., 2008; Kleinpell et al., 2008). While evidence does not confer a specific survival benefit for patients admitted to an ICU with APP staffing (Costa et al., 2014), evidence does demonstrate positive financial and clinical outcomes related to ventilator-days and length-of-stay in the ICU, as well as improved patient care flow and enhanced collaboration and interdisciplinary communication (Kleinpell et al., 2008; Costa et al., 2014). The APPs in the SICU are increasingly invested in all performance-related issues. In addition to providing direct patient care, the APPs are active in unit-based and hospital-wide committees, as well as SICU nursing-shared governance councils. For example, we designed and implemented the SICU Resident Orientation Handbook which outlines all of the key documentation requirements, order management expectations, and policies of the SICU. We orient rotating residents monthly with this tool. We host lectures for APPs and bedside nurses to broaden their understanding of many diagnoses and management plans commonly seen in the SICU. We served as provider champions for the transition to Portfolio and participated in the design of nearly all of the order sets and notes used on our unit. We also collaborated with nursing and the Department of Anesthesiology to devise a program called Operation Hard Stop in which we announce a Hard Stop upon the arrival of every patient from the operating room. Information regarding the surgery, anesthesia, and immediate post-operative management is exchanged and documented using surgical-service-specific handoff tools. Our APP group, in collaboration with nursing, took the lead in developing these tools with the surgical services. We believe this project has greatly enhanced interdisciplinary communication and patient safety. Nearly three years have passed since the introduction of APPs into the blended-provider SICU model. With the support and investment of nursing leadership, our past and current medical directors (Matthew Lissauer, MD and Samuel Tisherman, MD, respectively), as well as regular education from our attending physicians, the APPs in the SICU have transitioned from novices to team leaders, patient advocates, and unit champions. References Accreditation Council for Graduate Medical Education. (2011, July 1). Common program requirements. Retrieved from http://www.acgme.org/Portals/0/PDFs/Common_ Program_Requirements_07012011[2].pdf Costa, D.K., Wallace, D.J., Barnato, A.E., Kahn, J. (2014). Nurse practitioner/physician assistant staffing and critical care mortality. Chest, 146(6), 1566-1573. Garcia et al. (2008). Critical care nurse practitioners improve compliance with clinical practice guidelines in “semiclosed” surgical intensive care unit. Journal of Nursing Care Quality, 23(30), 338-344. Kleinpell, R.M., Ely, E.W., Grabenkort, R. (2008). Nurse Practitioners and physician assistant in the intensive care unit: an evidence-based review. Critical Care Medicine, 36(10), 2888-2897. Ward et al. (2013). Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing. Critical Care Medicine, 41(2), 638645. Ward, N.S. & Howell, M. (2012). Strategies to meet the needs of the ICU workforce. Critical Connections. Retrieved from http://www.sccm.org/Communications/CriticalConnections/Archives/Pages/Strategies-to-Meet-the-Needs-of-the-ICU-Workforce.aspx

Spring 2016

Spotlight on Pharmacy

Anticipating Updates to USP <797> and <800> Jueli Li, PharmD

In September 2012, the meningitis outbreak at the New England Compounding Center in Framingham, Massachusetts caused 64 deaths and over 700 lingering illnesses in individuals due to a fungal contamination in their sterile compounding facility (CDC, 2015). This incident came shortly after reports of other compounding pharmacies across the country that had also caused patients harm as a result of sterility concerns (U.S. FDA, 2016). These national catastrophes helped highlight the importance of appropriate oversight and federal regulation for the proper and safe handling of not only compounded medications, but all pharmacologic agents to prevent harm to any individuals. USP <797>

Compounding is one of the cornerstones of pharmacy practice. Compounding occurs when ingredients are combined, mixed, or altered to create a tailored medication to an individual patient, such as for those who have specific allergies or require different routes of administration (CDC, 2015). As a result of the manipulation, these compounded agents are not approved by the U.S. Food and Drug Administration (FDA), and thus may be contaminated if prepared using poor quality practices (U.S. FDA, 2015). FDA and state boards of pharmacy oversee all compounding facilities to ensure compliance with current good manufacturing processes and the national standards as set forth by the U.S. Pharmacopeia (USP) to prevent the adulteration of compounded medications. USP <797> pertains to sterile preparations and is being updated to improve processes to prevent sterility concerns in compounded products (USP, 2016). Changes to the <797> standards include simplifying the contamination risk levels from low, medium, and high-risk to just two categories based on length of the maximum beyond use date, recommending more guidance on the training, evaluation, and re-qualifications of compounding personnel, improving documentation and record-keeping, as well as relocating hazardous drug (HD) handling recommendations to USP <800>. The changes set forth in the most recent update hope to improve current sterile compounding practices in

order to prevent future health care crises similar to that in Massachusetts. USP <800>

Drugs are deemed as hazardous by the National Institute for Occupational Safety and Health (NIOSH) by meeting at least one of the following criteria: carcinogenicity, teratogenicity or developmental toxicity, reproductive toxicity in humans, organ toxicity at low doses in humans or animals, genotoxicity, or by mimicking existing hazardous drugs in structure or toxicity (USP, 2016). Any HD may require additional containment strategies and precautions associated with its handling, distribution, and administration, such as donning additional personal protective equipment. In 2014, NIOSH published an updated guideline on HD that categorized HD as antineoplastic agents, non-antineoplastics, or those that pose reproductive-only hazards (CDC, 2014). As a result of the new categorization scheme, a larger number of pharmacological products were deemed as hazardous, including those previously deemed as “safe.” This posed a hurdle to many health systems that were suddenly challenged with how best to manage the sudden change in the level of hazardous risk. USP <800> updates were first published on February 1, 2016 and will be fully implemented by all hospitals nationwide by July 1, 2018 (U.S. Pharmacopeial Convention). The purpose of the new USP <800> guidelines is to describe the recommended practices and quality

standards for handling HD in health care settings in order to promote safety to the patient, worker, and environment. The new standards will allow health care institutions to determine whether to follow the full, comprehensive NIOSH HD list or to involve multidisciplinary task forces to complete risk assessments for each medication and formulation to determine site-specific practices. The assessments of risk will hopefully streamline the practices across all of the hospitals in the University of Maryland Medical System as we approach compliance to the USP <800> guidelines. Looking Forward

Changes in federal regulations and guidelines by USP <797> and <800> hope to continue to prevent harm to individuals working in a health care setting by introducing new workflows, documentation, and training requirements. It will be critical that individuals in all practice areas come together to help the University of Maryland Medical System move toward compliance with the new regulations. References Centers for Disease Control and Prevention. Multistate outbreak of fungal meningitis and other infections – Case count. Oct 2015. Retrieved from: http://www. cdc.gov/hai/outbreaks/meningitis-map-large.html. Centers for Disease Control and Prevention. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings. 2014. Retrieved from: http://www. cdc.gov/niosh/docs/2014-138/pdfs/2014-138.pdf. U.S. Food and Drug Administration. The special risks of pharmacy compounding. Feb 2016. Retrieved from: http://www.fda.gov/ForConsumers/ ConsumerUpdates/ucm107836.htm. U.S. Food and Drug Administration. Compounding and the FDA: Questions and answers. Oct 2015. Retrieved from: http://www.fda.gov/Drugs/ GuidanceComplianceRegulatoryInformation/ PharmacyCompounding/ucm339764.htm. U.S. Pharmacopeia. Standards for compounding sterile preparations go under major revision. Sep 2015. Retrieved from: http://www.usp.org/news/standardscompounding-sterile-preparations-go-under-majorrevision. U.S. Pharmacopeia. Frequently asked questions: <800> hazardous drugs – handling in healthcare settings. Feb 2016. Retrieved from: http://www.usp. org/frequently-asked-questions/hazardous-drugshandling-healthcare-settings. US Pharmacopeial Convention. Briefing. <800> Hazardous Drugs – Handling in Healthcare Settings, PF 40(3). http://www.usp.org/sites/default/files/ usp_pdf/EN/m7808_pre-post.pdf.

news &views Respiratory Care Services: Supporting our profession beyond UMMC Robin Smith, BS, RRT and Oswald Murray, MHA, RRT

The field of respiratory care is comprised of over 120,000 dedicated health care professionals nationwide. Working in acute care hospitals, rehabilitation and long-term care facilities, diagnostic centers, home care, and in many other supportive roles, respiratory therapists help contribute to the support of patients in all areas of the health care environment. At the state and national levels, administrative bodies work together to grow and advance opportunities where respiratory care professionals can further contribute. The American Association for Respiratory Care (AARC) is our primary professional governing body. The AARC works closely with the National Board for Respiratory Care (NBRC) which manages the credentialing process. In recent years, the AARC and NBRC have worked collaboratively to weave together the previously separate two-step credentialing process, with the goal of advancing the entry level standards for the profession. Both work to support the advanced credentialing process which allows therapists to attain specialty credentials in neonatal and pediatrics, adult critical care, and pulmonary function testing. There is additional collaboration with the Commission on Accreditation for Respiratory Care (CoARC) that provides oversight for the respiratory care education regulations which assure the quality and content of all respiratory care programs. Graduating with either an associateâ&#x20AC;&#x2122;s or bachelorâ&#x20AC;&#x2122;s degree, programs offer comprehensive training that couples well-rounded course curriculum work with hundreds of hours of clinical experience. To complement the national level, each state has a respiratory care board which helps promote local needs and works closely with the our state licensure board. The Maryland and D.C. (MDDC) Society of Respiratory Care actively represents respiratory therapists through education, political support where active lobbying is necessary, and engages in activities that promote our profession. Respiratory Care Services at UMMC has fully embraced its role in supporting the profession beyond the Medical Center. Staff at all levels have worked closely with all the governing bodies and with those respiratory therapists at member hospitals within the University of Maryland Medical System. In the last year, there have been many noteworthy activities or achievements that highlight this dedication. In December 2015, the MDDC Society for Respiratory Care held its annual election of officers and awards ceremony. Following a statewide election, Christopher Kircher, MHA, RRT-ACCS, was elected as the Baltimore City chapter representative, and Jen McGrain, BS, RRT, was elected as the director-at-large. Maria Madden, BS, RRT-ACCS, has agreed to work closely with the president of the MDDC Society to coordinate professionally-focused social events that will help pull respiratory therapists together and promote what we do for the public. In recent years, this has included segments on a local morning news program and events where respiratory therapists came together to support charitable initiatives. Most noteworthy during this same MDDC society event were award presentations that were made for therapists making strides in their dedication to patient care. These individuals were all nominated by their peers and were deserving of the recognition.

Nichole Bradley, RRT-NPS, was recognized as Neonatal Respiratory Therapist of the Year, and Madden was recognized for having received the 2015 Critical Care Therapist of the Year Award by the AARC. Additionally, Nader Habashi, MD was recognized with the Excellence in Cardiopulmonary Medicine Award for his far-reaching dedication to respiratory care, both at UMMC and nationwide. Rob Smith, BS, RRT, has served on the professional standards committee for the Maryland Board of Physician Quality Assurance (BPQA) for the last four years. In this role, he helps maintain a strong connection between our state license stipulations and everyday practice. Helping to provide close oversight has required continued reflection of our professional scope of practice and code of conduct statements. Additionally, this group works closely with the board of the MDDC Society to keep the respiratory therapists in Maryland well informed regarding licensure and any clinical or regulatory changes that may affect their practice. To fully embrace partnerships with the future of the profession, UMMC has active affiliation with ten college programs to provide clinical rotations for students in the advanced portions of their education. This support results in a continuous flow of student respiratory therapists here at UMMC which immediately solidifies their interest in critical care respiratory therapy and their pursuit of professional opportunities available at the Medical Center. In 2016, we have had the pleasure to recruit many who have been drawn by the advances we are creating here at UMMC. In July, we will be hiring many new graduates who have shown great enthusiasm and desire to be a UMMC respiratory care therapist. It is through the recognition previously mentioned and by those who demonstrate an excellence in practice here at UMMC, that others are seeking to join our team. The dedication to this field was recognized at the 2016 Shock Trauma Gala where respiratory therapist Cecily Defreitas, RRT, was recognized as one of the Trauma Heroes. UMMC pride is very real for the respiratory care team. The work is challenging and rewarding, and even though emotional, it also provides an opportunity to demonstrate empathy. It is above all else meeting the call to care for our patients that brought us all to health care. The leadership team for respiratory care is dedicated to the advancement of the profession and is working hard to set new standards at both the state and national level. Whether it be at the bedside, in departmental or interdisciplinary committee work, growing through the professional advancement model, or recognition at the state and national levels, the very talented staff of respiratory care professionals are working hard to make UMMC proud of their efforts.

Spring 2016

Core Measures

Tobacco Treatment and Substance Use Core Measures Patty Dumler, BSN, RN, Core Measures Coordinator

With the retirement of selected core measure sets by The Joint Commission (TJC) and The Centers for Medicare and Medicaid Services (CMS), hospitals are required to select additional measure sets to fulfill the requirement of six measure sets to be reported. The University of Maryland Medical Center selected the tobacco treatment and the substance use core measures to meet this reporting requirement.

There is no doubt that tobacco, alcohol, and drug use can negatively impact health. We see it in the patients that we care for every day – diseases caused or worsened by the misuse of these products. Data collection for these two new measures started with January 1, 2016 discharges. Early data abstraction revealed that there is need for improvement with our compliance with the UMMC tobacco policy, EOC-003, and enhancement of assessment tools and patient education for the substance use measure. Identified areas for both measures include: w Tobacco use assessment not

completed in the Nursing Navigator; w Smoking education not documented; w Nicotine replacement therapy not w

w w w

being ordered; Referral for outpatient counseling and NRT prescription not provided at discharge; Validated unhealthy alcohol use screening tool not available; Brief intervention for unhealthy alcohol use not available; and Alcohol or other drug use treatment at discharge, not capturing all patients.

Table 1 shows each measure in the left-hand column. The righthand column shows what needs to be accomplished to meet the measure, be compliant with our smoking policy, and provide evidenced-based care for our patients.

New Core Measure

What Needs to be Accomplished to Meet the Core Measure

Tob-1 Tobacco Use Screening – Patients who are screened within the first three days of admission for tobacco use within the past 30 days

Nursing – Assess all patients for smoking in the Admission Navigator – includes patients that quit within past 30 days.

Tob-2 Tobacco Treatment Provided or Offered – Patients who receive or refuse practical counseling AND receive or refuse FDA-approved cessation medications within the first three days after admission

Nursing – Provide and document smoking cessation counseling or refusal of counseling within 3 days after admission. Working with Epic to have BPA fire to the inpatient orders for nicotine replacement therapy, if not already ordered – based on smoking screening.

Tob-3 Tobacco Use Treatment Provided or Offered at Discharge – Patients who were referred to or refused evidenced-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication upon discharge

BPA will fire if NRT not ordered with discharge meds – coming soon.

SUB-1 Alcohol Use Screening – Patients who are screened within the first three days of admission using a validated screening tool for unhealthy alcohol use

Validated screening tool for RN assessmentAudit C – coming soon.

SUB-2 Alcohol Use Brief Intervention Provided or Offered – Patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during hospitalization

Substance abuse consults in place Coming soon – substance abuse education by RN

SUB-3 Alcohol or Other Drug Use Disorder Treatment Provided or Offered at Discharge – Patients who received or refused at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who received or refused a referral for addictions treatment

Working with medical staff

1-800-QUIT-NOW phone call activated prior to discharge – coming soon.

Table 1: Specifications Manual for National Hospital Inpatient Quality Measures; Discharges 10-1-15 (4Q15) through 6-30-16 (2Q16); Version 5.0

news &views Safe Patient Handling & Mobility with the Mobile Practitioner Team at UMMC Lisa Petty, BSN, RN, CCRN, HNB-BC, Senior Clinical Nurse I and Molly Zublick, BSN, RN, Clinical Nurse II, Mobile Practitioner/Rapid Response Team

Nurses know how easy it can be to move a patient up in bed quickly, or slide a patient over to a stretcher with a little assistance. But is it actually a good practice? The potential for patient injury is a consequence of mishandling. According to the Bureau of Labor Statistics (BLS), nursing is rated in the top six of at-risk working occupations for musculoskeletal disorders. These injuries lead to nurses vacating the bedside for less physically demanding positions, which contribute to the growing nursing shortage (BLS, 2016). In 2013, the American Nurses Association (ANA) released national standards for Safe Patient Handling and Mobility (SPHM). These standards were put in place to create a safer work environment and to prevent injury for both patients and health care workers. They apply to hospitals and include a framework to eliminate manual handling of patients (ANA, 2013). There are SPHM guidelines available from several organizations, including the Society of Critical Care Medicine, the Occupational Safety & Health Administration, and the National Association of Orthopaedic Nurses. In addition, the Association of periOperative Registered Nurses has a tool kit for SPHM. These resources provide information needed to improve SPHM. The University of Maryland Medical Center (UMMC) supports SPHM and has a policy in place, COP-007, called Safe Patient Handling and Movement. This policy covers maximum weight limits and training information, with attachments for support on patient assessment, early mobility guidelines, mobility screening, patient movement, equipment, slings, and lift devices. It also includes where to obtain devices and the purpose of their use. This policy includes a contact number for ergonomics if assistance is needed. The Mobile Practitioner Team (MPT) at UMMC is a skilled group that specializes in the movement of critical care patients throughout the facility. The high acuity of these patients requires monitoring during transport at the same level they are receiving in the intensive care setting. The MPT assumes full care of the critically ill patient while away from the intensive care unit. A critical care registered nurse and patient care technician compose the team that transports the patient. Each member of the team must demonstrate critical thinking skills, competency in advanced assessment, and the ability to evaluate and intervene in critical situations. Pre-transport preparation is required for tests and procedures and must be coordinated with the test areas and the MPT. As part of the triage process, the MPT is responsible for obtaining necessary information prior to transport and testing.

This includes information about the procedure, appropriate intravenous access obtained, airway, completion of contrast, preventative measures, and procedural area readiness. According to Day (2010), no critically ill patient should have to wait in a hallway or holding area, thus pre-transport preparation is critical. Report from the bedside nurse is a key component before traveling with the patient. The Joint Commission implemented a standardized approach to handoff communication, which is a national patient safety goal. During handoff, the patientâ&#x20AC;&#x2122;s current condition and care plan should be reviewed (Day, 2010). SBAR (situation, background, assessment, recommendation) is used by the MPT to obtain report from the bedside nurse, which gives pertinent information to effectively care for the patient during the transport. Upon arrival and assessment, the MPT determines if the patient is appropriate for transport. The MPT requires specific equipment to complete the transport safely and effectively for the patient and staff: a cardiac monitor, ample supply of medications and intravenous fluids, resuscitation bag, appropriate oxygen source, and a stretcher. Any unwarranted equipment will be disconnected, as tending to it could cause unnecessary interruptions in patient care. The goal is to minimize distraction, keeping the transport simple, without compromising critical care needs (Day, 2010). The safest, most efficient route to the procedural area should be considered prior to transporting the patient. The MPT pre-plans each transport prior to leaving the unit. UMMC is a 772 licensed-bed facility with with multiple procedural areas. Traveling through the Medical Center is a very difficult task based on its size alone. Additional important factors that influence patient transport include the acuity of patients, elevator size, any unforeseen obstacles along the way, equipment, and availability of resources to address emergency needs. The MPT uses a stretcher which is the safest, most reliable, and ergonomically correct way to transport patients throughout the facility. In a literature review by Droogh et al. (2015), it was established that â&#x20AC;&#x153;all equipment must be lightweight and suitable continued on page 23.

Spring 2016

Toward a High Reliability Organization: Unit-Based Safety Clinicians and the UMMC Patient Safety Net Deborah L. Schofield, DNP, CRNP, FAANP, Director, Patient Safety and Quality and Mangla Gulati, MD, FACP, SFHM, CPPS, Vice President, Safety and Clinical Effectiveness

Our journey towards becoming a High Reliability Organization (HRO) continues. What is an HRO? These are industries constantly at high risk of catastrophic events; examples include airlines, nuclear power plants, aircraft carriers and health care. The five traits of high reliability organizations are: (1) sensitivity to operations (pay attention to what is not working well); (2) reluctance to oversimplify the reasons for problems (keep asking what happened and why); (3) preoccupation with failure (anticipate where the next error may occur); (4) deference to expertise (include those who do and hence understand the work best); and (5) resilience (prepared in how to respond to failures and continually find new solutions)(Gamble, 2015). To become an HRO, all who work in the organization are engaged and empowered. To this end, we have created and implemented a “Patient Safety Net” – groups of professionals who are passionate about ensuring the care we provide is both quality-driven and safe. These individuals are from interdisciplinary backgrounds with a passion surrounding safe care and for their demonstrated independent initiatives on their respective units/areas of specialty. The Patient Safety Net includes five distinct groups which function both independently and collaboratively on larger system safety and quality issues. These groups include the Council for Hospital and Ambulatory Patient Safety, Patient Safety Risk Mitigation Group, Quality Improvement and Patient Safety (a resident-led group), and the Unit-Based Safety Clinicians (UBSCs) – all closely working with the Department of Quality. As a first point of focus, we are very excited to introduce our first cohort of UBSCs. They are Nancy Berry, BSN, BS, RN (Stoler Pavilion); Amanda Fritsch, BA, RN, (Multi Trauma); Laura Bothe, BSN, RN, PCCN (Multi Trauma/Orthopaedics); David Glenn, MS, RN (BMT); Bobbie Perrault, BSN, RN, CCRN (PICU); Julie Kieliszak, MS, RN, AGACNP-BC, ACCNS-AG, CCRN, CNRN (Neuro ICU); Kirsten Tomaschefsky, BSN, RN, CCRN (MICU); Melissa Custer, BSN, RN, CCRN (SICU); Cheryl Ann Horn, MS, RNC, (NICU); Anne Johnston, BSN, RN, CCRN (Interventional Radiology); Rebekkah Friedrich, BSN, RN, CCRN (SICU); and Kara Stevens, MS, RN, CMSRN (Medicine 13E/W). These frontline providers/UBSCs are aligned strategically with the nurse manager and medical director on each respective unit. The UBSCs are charged with: real-time identification and strategies on their respective units to address safety issues, adoption of best clinical practice/protocols to enhance unit safety; increased safety reporting, including “near misses;” participation in “root cause analyses” on their respective units; and communication via safety huddles of safety issues occurring outside of their respective units. The preparation of UBSCs to function in this role includes formal didactic sessions based on curriculum from the Institute for Health Care Improvement (IHI) and the National Patient Safety Foundation’s six domains of safety: safety culture, leadership, risk identification and analysis, data management system design, systems thinking and human factors analysis, and external

Death or Harm No Harm Event No actual harm but potential exists

Near Miss Unwanted consequence prevented because of recovery

Dangerous Situations Errors and Deviations

Figure 1: Iceberg Concept of Accidents and Errors – Agency Healthcare Research and Quality (AHRQ)

influences on patient safety. In addition to this formalized learning, there will be assigned relevant reading and online materials to complete. Upon the completion of the learning, each UBSC will complete an evidenced-based project on their unit, which encompasses a safety issue, and present to the larger group to share their learnings and effective strategies. The second cohort and “call” for UBSCs will be in July 2016. The Council for Hospital and Ambulatory Patient Safety (CHAPS) is a group of clinicians who are also frontline providers. Many safety issues are not unique to specific units; rather, they represent more systemic issues. This group will seek evidence-based and best practices that can be applied at an institutional level. The CHAPS group will work closely with the UBSCs – all toward an inter-professional organizational approach to patient safety. Additionally, as a large academic medical center, with trainees and learners from several different professional schools on campus, we have the opportunity to inculcate patient safety and quality continued on page 23.

news &views High Reliability Organization and the UMMC Patient Safety Net,

Safe Patient Handling with Mobile Practitioner Team,

continued from page 22.

continued from page 21.

improvement as we train, teach, and lead the next generation of health care providers. The Quality Improvement and Patient Safety Group (QIPS) is a resident-led group with over 100 participants. The group meets monthly and includes residents, medical students, advanced practice providers, pharmacists, and nurses. Although much work and innovation has occurred surrounding patient safety since the Institute of Medicine’s 1999 report, “To Err is Human” (IOM, 1999) was published, progress has been slower than expected as evidenced in the article; “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care” (Journal of Patient Safety, 2013). To address all that lies beneath the surface of the iceberg, (see figure 1) all employees are encouraged and should feel empowered to report safety concerns to supervisors or via the Risk Management Incidence Reporting tool (RL Solutions*) and/or 8-SAFE. This allows us to address the concern by asking the “three Ws:” what happened, why did it happen, and what can we do to assist in avoiding it in the future? Also, as a follow-up to the intervention to avoid future similar events, how action plans and interventions were effective in alleviating the safety threat or adverse event. The UMMC journey to becoming an HRO is rapidly evolving as evidenced by the aforementioned groups, their respective charges, and their collective learning and collaborative initiatives - all to ensure the safest care for all patients and those who care for them as the top priority at UMMC. * To access RL Solutions, go to the home page of the UMMC Insider and click on Event Reporting under Patient Care Quick Links. References Gamble, M. (2015). Five Traits of High Reliability Organizations: How to Hardwire Each in Your Organization. Retrieved from: http://www.beckershospitalreview. com/hospital-management-administration/5-traits-of-high-reliabilityorganizations-how-to-hardwire-each-in your-organization.html Institute of Medicine. (1999). To Err is Human: Building a Safer Health System. Retrieved from http://iom.nationalacademies.org/Reports/1999/To-Err-isHuman-Building-A-Safer-Health-System.aspx Journal of Patient Safety. A New Evidence-based Estimate of Patient Harms Associated with Hospital Care, volume 9(3), September 2013, 122–128.

for transfer conditions.” The use of the stretcher is beneficial for the patient and the staff that is caring for the patient during transport. The MPT searches for evidenced-based practices to improve patient outcomes and maintain a safe environment during intra-facility transports. Therefore, utilizing the MPT for patient transport provides great benefits for patient safety and helps to reduce complications and adverse events from occurring in the workplace. The MPT hopes to establish a culture of safety in order to promote safe patient outcomes by preventing injury and/or adverse events to patients, and to prevent injury to the nurses and assistive personnel. Implementing evidenced-based practice for SPHM reduces injuries and costs to both patients, health care workers, and the organization. The use of stretchers allows for lighter patient load, more accessibility through the hospital, appropriate space in procedure areas, better access to patients in case of an emergency, and the option to follow different/quicker routes throughout the hospital. Creating policies and healthy work environments to include SPHM will introduce a strong culture of safety in the hospital setting (Powell-Cope & Rugs, 2015). Continued attention by unitbased leaders, planning in advance, and utilizing the MPT will also support SPHM. In turn, this creates an atmosphere of leadership in quality and safe outcomes for both patients and staff. References American Nurses Association. (2016). Handle With Care Fact Sheet. American Nurses Association. (2013). ANA Unveils National Standards for Safe Patient Handling and Mobility To Spur Commitment to Culture of Safety. Bureau of Labor Statistics (BLS). (2015). Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, 2014. Day, D. (2010). Keeping Patients Safe During Intrahospital Transport. Critical Care Nurse. 30(4): 18-32. Droogh, J. M., Smit, M., Absalom, A. R., Ligtenberg, J. J., & Zijlstra, J. G. (2015). Transferring the critically ill patient: are we there yet? Critical Care, 19(1), 62. Powell-Cope, G., & Rugs, D. (2015). What Elements of the 2013 American Nurses Association Safe Patient Handling and Mobility Standards are Reflected in State Legislation? American Journal of Safe Patient Handling & Movement. 5(1), 13–18.

Would you like to have your article published in News&Views ? Submitted articles should: • Present clinical and professional nursing practice topics in inpatient, procedural and ambulatory areas that are evidence-based, innovative, and outcomes driven. • Focus on divisional, departmental and/or organizational strategic goals. See page 2 for submission guidelines. For more information or to submit content for a future issue, please contact Susan Carey at scarey@umm.edu

Spring 2016

Cardiac Advance Life Support (CALS) at the University of Maryland Medical Center Stacy Foertsch, BSN, RN, SCNI; Lauren Espeso, BSN, RN, CCRN, SCNI and Richard Bell, BSN, RN, CCRN-CSC, SCNII, Cardiac Surgery Intensive Care Unit

The only course of its kind in the mid-Atlantic region, Cardiac Advance Life Support (CALS) is now being offered at UMMC and taught by instructors in the Shock Trauma Center (STC) Simulation Lab. After twelve months of training for our internal staff, the course was opened to the public in January 2016. Approximately 110 UMMC staff members, and about 40 non-UMMC staff have been trained in this “high acuity, low probability” course. You might ask as to what is all of the excitement about? Background In 2002, a group of dedicated United Kingdom (UK) surgeons and cardiac surgery staff embarked upon the development of a resuscitation protocol designed specifically for postoperative cardiovascular surgical (CVS) patients. After several years of research and clinical practicums, the Cardiac Surgical Unit Advanced Life Support (CSU-ALS) course was created and offered for the first time in 2004 (Dunning et al., 2005). In 2009, Jill Ley, MS, RN, CNS, traveled from California Pacific Medical Center in San Francisco to the United Kingdom to attend a course taught by Joel Dunning, MD and others. Upon her return to the U.S., Ley partnered with a group of health care professionals on the west coast to develop a one-day CALS program that could be offered in the U.S. CALS has been the official protocol in the UK for postoperative cardiac surgery patients since 2010. In January of this year, the CALS program was presented at a conference for the Society of Thoracic Surgeons (STS) and it is expected it will be approved in May 2016 as the standard of care. Today In early 2015, a group of CSICU staff – nurses, nurse practitioners (NPs), physician assistants (PAs), and physicians – attended a CALS train-the-trainer course at Suburban Hospital in Bethesda, Maryland. The knowledge and skills learned in this class were brought back to the cardiac surgery team at UMMC. With the support of a multi-disciplinary team of health care providers and through hard work and discipline, the program began to take shape. Now, sixteen months later, the UMMC program is growing with each and every course taught. It is open to RNs, NPs, PAs, MDs, pharmacists, and respiratory therapists who work within the cardiac surgery field and wish to learn this evidence-based approach to the resuscitation of postoperative heart patients. The eight-hour course is a combination of didactic lectures, as well as hands-on practice in the Simulation Lab using our highly specialized CALS manikin. We have had the opportunity to assist in the presentation of this course during a ninety-minute breakout session at the Foundation for the Advancement of Cardio Thoracic Surgical Care (FACTS-Care) critical care conference held in Washington D.C. in October of last year. We have also displayed a poster on this unique education and a few of our outcomes at the Maryland Nurse Association conference in October 2015. We have had students come from as far away as Texas, Florida, Connecticut, continued on page 25.

Left to right: Richard Bell, BSN, RN, CCRN-CSC, SCN II; Lauren Espeso, BSN, RN, CCRN, SCNI; and Stacy Foertsch, BSN, RN, SCNI

Poster on CALS education for staff

news &views Cardiac Advance Life Support (CALS), continued from page 24. and Maine to attend this novel and unique course, as we are also able to offer 7.5 hours of continuing education credit. Course objectives include: distinguishing critical differences between protocols for ACLS versus CALS (Ley et al., 2015); identification of the six key roles; use of the five-piece surgical surgical set; successful CALS re-sternotomy within five minutes (Dunning et al., 2012); and identifying unique features of the cardiac surgery patient that warrants modification to the standard resuscitation technique. Since initiating this course in February 2015, the staff at UMMC have witnessed, first-hand, the algorithm in use at the bedside. The protocol has been used eleven times in 2015 in the CSICU and our patient outcomes have been positive. After taking the course, staff feels considerably more comfortable and organized during these stressful emergency situations. The feedback that we have received from class evaluations has shown that there has been marked improvement in our teamwork, communication, and role identification, thus alleviating confusion and errors. References Dunning, J., Levine, A., Chaudhry, S. (2005, November 5). Running a Cardiac Surgery Advanced Life Support Course. British Medical Journal, pp. 200,201. Retrieved from http://careers.bmj.com/careers/advice/view-article.html?id=1237# Dunning, J., Levine, A., Strang, T., Bartley, T., Ley, J., Kirmani, B. (2012). The Cardiac Surgery Advanced Life Support Course 2nd edition. Joel Dunning Publishers, UK. Ley, S. Jill. Standards for Resuscitation after Cardiac Surgery. Critical Care Nurse, April 2, 2015, 35(2), 30-38. http://ccn.aacnjournals.org/

Steps to take in the event of a cardiac arrest

Key roles in cardiac arrest

Spring 2016

Achievements

Corbitt will serve as delegate to Vice President Biden’s Cancer Moonshot Summit Nancy Corbitt, BSN, RN, OCN, CRNI, Senior Clinical Nurse ll, has been nominated by the Oncology Nursing Society (ONS) and will serve as a delegate to Vice President Biden’s Cancer Moonshot Summit on June 29 in Washington, D.C.

Corbitt is currently the programs director for the Greater Baltimore Chapter of Oncology Nursing Society (GBCONS) and was past president of GBCONS, as well as their director-at-large. Nationally, Nancy just completed work on the

ONS Congress Planning Team 2016, as well as a three-year appointment on their leadership weekend retreat team. She has previously written a chapter on acute myeloid leukemia (AML) for ONS’s hematology web-course and is now working on a patient safety CEU web course. Nancy is also a team member for ONS on their evidence-based project focusing on prevention of bleeding in the oncology population.

Lighty Elected Chairperson of the Maryland Board of Physical Therapy Examiners Diana Johnson, PT, MS, BS, Director, Rehabilitation Services, Administrative Oversight, Clinical Nutrition & Respiratory Care Services

Krystal Lighty, PT, MPT is the inpatient manager of the Department of Rehabilitation Services. She recently completed her first year as chair of the Board of Physical Therapy Examiners.

This board has been in existence since 1947 to regulate the practice of physical therapy in the state of Maryland. The board’s eight members include five physical therapists, one physical therapist

assistant, and two consumer members. Board members are appointed to fouryear terms by the Governor with the advice of the Secretary of Health and Mental Hygiene. Lighty has served on the Maryland Board of Physical Therapy Examiners for five years, two of which she served as vice-chair. Her board term will expire on June 30, 2019. Lighty’s responsibilities as chairperson include management and oversight of board office activities. Duties of the board include writing regulations, interpreting the scope of practice, educating licensees, and disciplining those who violate the law. There are over 8,000 licensed physical therapists and physical therapist assistants combined in the state of Maryland. The board also makes rules and regulations governing the denial, suspension, and revocation of licenses. The most important function is protecting the citizens of Maryland. Board meetings are held every third Tuesday of the month and are open to the public.

Lighty has been with the Medical Center since August of 2001. She started as a physical therapist in neurocare and gradually advanced through the clinical ladder to serve as a senior therapist in Shock Trauma. In 2009, she was promoted to manager of the Department of Rehabilitation Services. Lighty has led many initiatives to optimize patient care models and enhance clinical best practices. Her latest efforts involve the hospital-wide early mobility program, which is being considered as a systemwide initiative. She currently manages Rehabilitative Services for the adult inpatient areas and serves on the Clinical Practice Council, Clinical Informatics Council, and the Clinical Best Practice group of the University of Maryland Rehabilitation Network.

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