News & Views by UMMS

news views Winter 2016

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

Lisa Rowen’s Rounds: Change is Constant at the Medical Center What is the one thing we can always count on, the one thing that is ever-present, the thing that, without a doubt, will always occur in our health care environment? The answer: Change. Every single day, something changes at the Medical Center.

Lisa Rowen, DNSc, RN, CENP, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer

Sometimes the changes are monumental events that occur with a “flip of the switch.” Implementing inpatient Portfolio was an event that altered workflows, documentation, and how we track performance and outcomes. The planning was painstakingly exquisite. The training was at times overwhelming. And the go-live was a bit of a roller-coaster ride that eventually glided smoothly, on schedule, to the station platform. It was a fast-paced, noticeable change – gravity-defying, all consuming and loud in the very public nature of its energy and emphasis. Sometimes the changes are challenging, subtle and slow. Our commitment to decreasing central lineassociated bloodstream infections and catheter-associated urinary tract infections has involved multiple evidence-based practice changes and multiple disciplines working together over many years, as well as the use of new supplies. All of this required intense vigilance, and it was worth it. The success of our efforts has led to saving more lives and reducing harm to patients. This type of change is profoundly positive. Moving to a more professional and standardized appearance through alignment of scrub wear has been a change that has also been profound. I’m not aware of any other hospital that has done what we have done – create a visibly unified care team via one color of scrubs – navy blue. Inspired by the single care team appearance of our Shock Trauma colleagues in pink, the rest of the staff in the Medical Center in non-sterile environments now wear navy scrub wear. Our Magnet colleagues have told us that this change is novel, innovative and a model for other hospitals. While wearing one color does not differentiate roles from each other, it does create the appearance of a single and aligned team of health care providers. It is a powerful and visible image that underscores our integrated work together for our patients. Every day and night at the Medical Center offers each of us the constancy of change. Just as the earth changes from moment to moment, so does our world of patient care. It is comforting to know our world, whether external or internal to the Medical Center, offers us the possibility to continuously change with the purpose of improvement. As we focus on the areas of our professional practice that we want to improve, I’d like to challenge you to consider big and small changes, changes that you can make alone or in teams, and changes that are both obvious and inspired. Each of us brings creativity and innovation to our teams and work environments. Unleash this energy to create change that evolves our patient care to be the best that it can possibly be, until you find the next way to make it even better.

“Unleash this energy to create change that evolves our patient care to be the best that it can possibly be, until you find the next way to make it even better.”

Winter 2016

In This Issue 1

Lisa Rowen’s Rounds

Corporate Compliance

Celebrating Magnet Recognition

Spotlight on Pharmacy

Routine HIV Testing and Linkage to Care

Achievements

Alarm Identification and Response Simulation (AIRS) Study

Certification Corner

Pain Improvement Initiative

Quality of Life After the ICU

RISE Program Goes Live

Journal Club

Core Measures

Shock Trauma Center Violence Intervention Program

20 Becoming a High Reliability Organization 21

Mother/Baby Sleep Safe Innovations

Respiratory Care Week

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 alavarez1@umm.edu. Compliance FAQ Q: Your co-worker asked you to look up his mother’s chart in Portfolio to clarify the dosage of her Atenolol so that he doesn’t get “flagged” for accessing a family member’s record. A: Never access protected health information (PHI) for someone else unless you are on the same care team and are caring for the same patients. UMMC utilizes a robust proactive screening program to analyze EMR access.

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 Senior Vice President of Patient Care Services and Chief Nursing Officer Suzanne Leiter Executive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice and Professional Development, Neuroscience 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 Spring 2016 Summer 2016 Fall 2016 Winter 2017

DUE DATE May 2, 2016 July 11, 2016 October 3, 2016 January 2, 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 Celebrating Magnet® Recognition 2015 ANCC National Magnet Co nference ® Carolyn Guinn, MSN, RN, Magnet Program Director

The American Nurses Credentialing Center’s (ANCC) national Magnet® conference was held October 7-9, 2015, in Atlanta, Georgia, and was host to more than 9,000 nurses from all over the world – a record-breaking attendance. The conference is not just a celebration of being designated Magnet®; this professional gathering also facilitates sharing best practices originating from Magnet® organizations. The University of Maryland Medical Center (UMMC) is proud to say that two abstract submissions (posters) were accepted for presentation by our nursing staff at the conference. The first poster presentation, “The CAUTI Crew: The Story of Nurse-driven CAUTI Reduction Initiative,” by Ashleigh N. Stronski, BSN, RN, CCRN; Jennifer (CJ) L. Meyer, BSN, RN, BA, BS; and Devin Williams, BSN, RN, CCRN, focused on reducing CAUTI in the Neurotrauma Critical Care unit. The “CAUTI Crew” was a multidisciplinary team of nurses and physicians formed by Stronski as part of a performance improvement project to support her senior clinical nurse I achievement. Stronski and co-author Williams were honored to present the work of this team and the excellent patient outcomes this group achieved (see photo on page 4). The second poster presentation was “Behavioral Emergency Response Team: Implementing a Performance Improvement Strategy to Address Workplace Violence,” by Constance Noll, MA, MSN, RN-BC, and Karen Doyle, MBA, MS, RN, NEA-BC. Noll presented on the development of UMMC’s Behavioral Emergency Response Team and the impact this team is making on the safety of our patients and staff (see photo on page 4). This is an innovative practice at UMMC and we are proud to disseminate this excellent work with our colleagues at the national level. Congratulations to these outstanding nurses for being recognized by the Magnet program for excellence in nursing practice! Please enjoy the following reflections provided by a few of the participants who attended this year. Hopefully this information will inspire individuals to not only attend the conference but also to participate as agents for practice change that promote excellent outcomes for all. The next annual Magnet conference will be held October 5-7, 2016, in Orlando, Florida.

MAGNET

REFLECTIONS

Reflection by Kimmith Jones, DNP, RN, RN-BC

Director, Translation to Nursing Practice

The Magnet® conference was an exhilarating experience. Thousands of nurses converged on the convention center to share their experiences of improving patient care and celebrate the organizations that were newly or renewedly designated this past year. The excitement and enthusiasm in the general and breakout sessions was palpable and provided the stimulus to think creatively about how we could do things better at the Medical Center. I attended many interesting sessions at the conference. There were a few that I found particularly interesting. One session focused on Ebola preparedness. The presenters described their approach to keeping their team knowledgeable and ready for the next patient that may arrive. Another session addressed orientation of new hires and the use of simulation to assess and develop competency. During a third session, an organization described the approach they used to review and revise its professional practice model and assure it remained relevant to the environment. One of the things I enjoyed the most was attending and reviewing the multitude of posters during the poster sessions. The research, evidencebased practice, and process improvement initiatives that organizations are conducting is stellar, many of which are initiatives or practices that we have embarked upon at the Medical Center. It made me realize that we have very valuable stories to tell and should be submitting many more abstracts for consideration continued on page 4. to future Magnet® conferences.

Winter 2016

Celebrating Magnet Recognition, continued from page 3. Reflection by Ashleigh Stronski, BSN, RN, CCRN, CNI

Neurotrauma Critical Care

Reflection by Devin Williams, BSN, RN

Nurse Coordinator Neuro Division

Connie Noll, MA, MSN, PMHRN-BC, CRNP and her poster at Magnet® conference in October.

The Magnet conference was truly energizing! Not only were the participants able to listen to lectures and presentations from many motivational and influential nurses/speakers, but experiencing a conference with over 9,000 passionate nurse colleagues who are striving to learn best patient care practices is amazing! The conference had a wide array of sessions available each day, making it difficult to choose from the many interesting topics. Some of the sessions I was able to attend featured topics such as: reducing nurse fatigue, addressing staffing issues, implementing a peer review process, advanced nursing degrees, and wellness coaching. Having a special interest in reduction of nurse fatigue, there were several ideas that I found would be beneficial to the staff at UMMC, including a special program developed by the American Nurses Association to tackle this growing phenomenon and designing a relaxation room for nurses to utilize during their shifts. My most enjoyable moment of the conference was being able to present our “CAUTI Crew” poster during the conference poster sessions. During this time, I was able to discuss and disseminate CAUTI reduction and prevention strategies that were developed by the nursing staff in the Neurotrauma Critical Care Unit. It was wonderful to meet and engage in crucial conversations with such an eager and diverse group of professionals who spanned across the world. Having the opportunity to represent UMMC at the national level with a project that impacts health care outcomes and, more specifically, the outcomes of my unit (Neurotrauma Critical Care) was one of the most rewarding experiences in my nursing career. By presenting the CAUTI project to our nursing peers, we learned that this continues to be Left to right: Ashleigh Stronski, BSN, RN, CCRN and Devin Williams, BSN, RN a “hot topic” in health care. This opportunity allowed us to network with other nurses who are implementing various strategies to reduce CAUTIs and provided us with different ideas that our CAUTI team had not yet explored. The Magnet® conference also had a really impressive opening ceremony with guest speakers, including Alton Brown from the Food Network who spoke to all 9,000 in attendance about how to keep ourselves healthy so we can care for others. The celebration party for the conference attendees was very cool because it was held in the amazing Georgia Aquarium with great food and drink. I would recommend to anyone to seek out the opportunity to present at the Magnet® conference, as this is a once-in-a-career event!

news &views Spotlight on Pharmacy

Drug Shortage Update Anupama Divakaruni, PharmD candidate University of Maryland School of Pharmacy

Over the last decade, the number of drug shortages has increased dramatically, putting a strain on our health care system, both in terms of the quality of care provided and the financial implications.1

Although the American Society of Health System Pharmacists (ASHP) and the Food and Drug Administration (FDA) each track drug shortages, each organization defines this differently.1 The ASHP describes a shortage as “a supply issue that affects how the pharmacy prepares or dispenses a drug product or influences patient care when prescribers must use an alternative agent.”1 The FDA’s definition, however, focuses on “products used to prevent or treat a serious lifethreatening disease or medical condition for which there is no other available source with sufficient supply of that product or alternative drug available.”1 The number of drug shortages identified increased from 61 in 2005 to over 250 in 2011. Despite the number of shortages decreasing to 117 in 2012 and 44 in 2013, there is still a significant burden on the health care system.2 Drug shortages can happen for a variety of reasons, including lack of access to raw materials, obstacles with manufacturing noncompliance to regulatory standards, and business and economic influences.1 The supply of raw or bulk materials can be disrupted due to manufacturer discontinuation, natural disasters, variation in climate, quality concerns, and the global supply chain.1,3 Drug manufacturers also play a major role in drug shortages because of equipment defects, mergers and personnel changes, and anticipated demand.1 They may decide to reduce or discontinue

production due to lack of profits, generic availability, or reallocation of resources to research and development.1 Regulatory issues and noncompliance with current good manufacturing processes can delay or interrupt production of a drug, which can be especially problematic when there is only one manufacturer of a particular drug. 1,3 The FDA has been at the center of implementing strategies to mitigate such shortages that can lead to delay or lapse in care, and use of alternate therapies that may be less effective or have more side effects. In July 2012, President Obama signed the FDA Safety and Innovation Act (FDASIA), which gave the FDA authority to regulate drug shortages. Under this act, manufacturers of biologics and all prescription drugs that are covered must provide notice to the FDA if a delay or interruption in production is foreseen. Additionally, this act authorizes the FDA to conduct expedited reviews of drug applications and/or expedited inspections, in an effort to alleviate the burden of a drug shortage. The agency continues to have better success, with 78 prevented drug shortages reported in the first three quarters of 2014.2 Consequences of drug shortages include rising health care costs, increased safety risks, and an overall burden to health care providers.1,3 When there is a drug shortage, non-traditional (gray-market) distributors can enter the market, purchase the remaining supply of the drug, and sell to hospitals and other health care facilities at an inflated price.1,3 Shortage of a particular drug will usually require an alternative drug to take its place, which may have an increased side effect profile or reduced efficacy.1 This impacts certain drugs like chemotherapeutic agents, which are more vulnerable to shortages than other drugs. As a result, providers are doing their best to provide the best care possible to their patients with the drugs they have available to them. At the University of Maryland Medical Center, drug shortages are no

exception to our daily routine. Our pharmacy department at UMMC is a core resource in mitigating the effect that shortages have on our patients and providers. Our pharmacists work with various other providers to update hospital policies and procedures that are affected by lack of availability of certain drugs. The clinical pharmacy team also assists in prioritizing which patients receive short-supplied drugs and helps to provide the best care possible. From a technological perspective, when a medication on shortage is ordered, there is a pop-up screen on the Portfolio interface to guide prescribers in choosing the best alternative agent. Drug shortages will continue to create a challenging practice environment for health care professionals, although it has greatly improved over the last year. Despite the unpredictability of impending shortages, collaboration is essential to strategic planning, revision of protocols and guidelines, and in keeping patient safety and outcomes as a top priority. For the most up-to-date information on drug shortages, you can visit the FDA website at http://www. accessdata.fda.gov/scripts/drugshortages/ default.cfm and the ASHP website at http://www.ashp.org/menu/DrugShortages/ CurrentShortages. Institution specific shortages can be found on the UMMC formulary page. References 1. Ventola CL. The drug shortage crisis in the United States: Causes, impact, and management strategies. P T [Internet]. 2011 11;36(11):740-57. Available from: http://search.ebscohost.com/login.aspx?direct=true& db=cmedm&AN=22346307&site=eds-live 2. Second Annual Report on Drug Shortages for Calendar Year 2014. http://www.fda.gov/downloads/ AboutFDA/ReportsManualsForms/Reports/ UCM443917.pdf 3. Anna Gu M, PhD, Wertheimer AI, Bernard Brown B, Bernard Brown B. Drug shortages in the US – causes, impact, and strategies. INNOVATIONS in Pharmacy [Internet]. 2011(4):60. Available from: http://search. ebscohost.com/login.aspx?direct=true&db=edsdoj&A N=58027d7f0071a631b8c7258a20df809e&site=edslive 4. Kehl KL, Gray SW, Kim B, Kahn KL, Haggstrom D, Roudier M, Keating NL. Oncologists’ experiences with drug shortages. Journal of Oncology Practice [Internet]. 2015 03;11(2):e154-62. Available from: http://search.ebscohost.com/login.aspx?direct=true& db=a9h&AN=101631741&site=eds-live

Winter 2016

Routine HIV Testing and Linkage to Care at UMMC Lucy Miner, BSN, RN, PCCN, Senior Clinical Nurse II, Division of Medicine, Surgery and Cardiovascular Medicine

Maryland is ranked third in the nation for new Human Immunodeficiency Virus (HIV) infections among U.S. states and territories. In the zip code where University of Maryland Medical Center (UMMC) is located, one in every 23 persons over the age of 13 is infected with HIV. In Baltimore City, HIV disproportionately impacts African-Americans where one person in 29 is living with HIV. National trends demonstrate the prevalence of HIV is higher among persons without a high school education, those unemployed, persons living below the poverty line, and the homeless. Baltimore’s continuum of care (see Figure 1 on page 7) depicts gaps in diagnosis, linkage to care, retention in care, and viral suppression among persons living with HIV. These gaps reflect the potential to leverage entry points in the health care system to identify new cases of HIV and link persons living with HIV to outpatient HIV care and treatment. included Lisa Rowen, DNSc, RN, CENP, FAAN, senior vice president for patient care services and chief nursing officer; Jonathan Gottlieb, MD, former senior vice president and chief medical officer; Jeffrey Rivest, FACHE, former president and chief executive officer; and Keith Persinger, MBA, executive vice president, chief operating officer and chief financial officer. Other service-specific stakeholders, including nurse and provider leaders, and individuals from the laboratory, finance/ billing and Information Systems and Technology, provided valuable insight and feedback while building and changing the program over time. Support for the RTP was easily attained, as each stakeholder reiterated repeatedly that this was the “right thing to do” for our patients. The RTP was launched in March 2013 across eight acute care medicine services, with the intermediate care service added in July 2013. Subsequently, the program expanded to include surgery, cardiovascular medicine, psychiatry, and orthopedics. In 2015, the adult and pediatric emergency departments were also added. The RTP started as a paper-based provider and nurse-driven initiative. To achieve a systematic and hospital-wide approach to HIV testing and linkage to care, an institutional protocol-driven order using the University of Maryland Medical System’s electronic medical record, Portfolio, was explored and built. Working with Dan Lemkin, MD, MS, FACEP, assistant professor of emergency medicine and director of medical informatics, and his dedicated team, an innovative, house-wide solution was developed. Lemkin built an electronic process in Portfolio that enabled the application to electronically assess inpatients for HIV test eligibility and then generate a best practice advisory (BPA) for eligible patients in the nursing admission navigator. The BPA prompted the admitting nurse to discuss routine HIV testing with the patient and order the test as a protocol order directly from that workflow. This standardized, electronic approach also facilitated a systematic process for linking patients with new and previous positive HIV test results to outpatient care and

Routine HIV Testing and Linkage to Care Program interdisciplinary leadership team. Left to right: Travis Brown, MS, MBA; Mangla Gulati, MD, FACP, SFHM; Shawn Hendricks, MSN, RN; Ruth Borkoski, BSN, RN; Christina Cafeo, DNP, RN, CENP; Jenna Canzoniero, MD; Janaki Kuruppu, MD; and Lucy Miner, BSN, RN, PCCN

In 2006, the U.S. Centers for Disease and Prevention Control recommended routine HIV screening for adolescents and adults in health care settings. To address the local epidemic and health disparities around HIV, UMMC partnered with the JACQUES Initiative of the Institute of Human Virology at the University of Maryland School of Medicine (JI) to develop the Routine HIV Testing and Linkage to Care Program (RTP). The development of the RTP was the result of a strong interdisciplinary leadership team that included Christina Cafeo, DNP, RN, CENP, vice president of patient care services and associate chief nursing officer; Mangla Gulati, MD, FACP, SFHM, associate chief medical officer and vice president of patient safety and clinical effectiveness; Jenna Canzoniero, MD, former chief resident, patient safety and quality improvement; Jamie Mignano, MSN, RN, MPH, director of development and information dissemination at the JACQUES Initiative; Travis Brown, MS, MBA, program manager, RTP, JACQUES Initiative; Lucy Miner, BSN, RN, PCCN, senior clinical nurse II, Division of Medicine, Surgery and Cardiovascular Medicine; Janaki Kuruppu, MD, assistant professor, Infectious Disease/Department of Medicine at the Institute of Human Virology; Shawn Hendricks, MSN, RN, nurse manager for 10E and 11E; and Ruth Borkoski, BSN, RN, nurse manager for 10W Medical IMC and 13E/W Acute Telemetry. UMMC executive sponsorship and support was obtained at the beginning and maintained throughout the progression of the program and

continued on page 7.

news &views Routine HIV Testing, continued from page 6.

supportive services through a JI Linkage to Care Navigator (LCN). The dedicated linkage to care team through the JACQUES Initiative consists of navigators Gene Chance, Massiel Garcia, BA, Kithia Gray, Don Kirk, MHS, Vanessa Lathan, BSW, and Kevin Thomas. Prior to the launch of the RTP, 3% of medicine patients were tested for HIV. Post implementation of the RTP, an average of 70% of eligible patients were tested for HIV (through October 2015), with approximately 80% of those patients accepting the test. Data showed that the majority of patients who were offered an HIV test in a scripted, routine way accepted the test. Figure 2 displays additional testing and linkage to care data for the RTP through 2015.

Figure 1

9155 44

• Pa$ents tested as part of the rou$ne HIV Tes$ng and Linkage to Care Program • Newly diagnosed HIV posi$ve pa$ents

307

• Previously diagnosed HIV posi$ve pa$ents out of care

85%

• Newly diagnosed HIV posi$ve pa$ents linked to outpa$ent HIV care *

52%

• Previously diagnosed HIV posi$ve pa$ents re-‐linked to outpa$ent HIV care*

Figure 2: Routine HIV Testing and Linkage to Care Program Results *Data from 2013 and 2014. Linkage to care data for 2015 is pending.

The RTP workflow in Portfolio has been live since last November in the adult and pediatric emergency departments and all acute and intermediate care units. The interdisciplinary leadership team and LCN are currently developing reporting within Portfolio to track how frequently and effectively nurses are using the BPA. Additionally, hospital-wide education efforts are taking place, specifically in areas where routine HIV testing is a new workflow. Plans for expansion into unique areas, such as the pediatric inpatient departments and the Trauma Resuscitation Unit, are in development. As routine HIV testing and linkage to care continues to become part of the standard of care for all admitted patients at UMMC, other ways to utilize this electronic workflow to solve similar public health-related issues are being explored. Work has begun to incorporate routine Hepatitis C Virus (HCV) screening and linkage to care into the existing Portfolio workflow. One third of HIV-infected persons are co-infected with HCV, with HCV disproportionately affecting minorities, those living in poverty, and those with a history of intravenous drug use.6,7 New therapy to cure HCV makes it more important than ever to screen for this chronic disease and link infected persons into outpatient care. The shift in health care to a focus on population health highlights the importance of routine testing and linkage to care efforts in the acute care settings. References 1. Maryland Department of Health and Mental Hygiene. (2013). Baltimore City HIV/AIDS Epidemiological Report: 4th quarter 2011. 2. Maryland Department of Health and Mental Hygiene. (2013). Baltimore City HIV/AIDS Epidemiological Report: 4th quarter 2011. 3. Centers for Disease Control and Prevention. (2011). Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence – 24 Cities, United States. MMWR: Morbidity and Mortality Weekly Report, 60, 1045-1049. 4. Baltimore City Annual HIV Epidemiological Profile 2013. Center for HIV Surveillance, Epidemiology and Evaluation, Department of Health and Mental Hygiene, Baltimore, MD. 2015. 5. US Centers for Disease Control and Prevention. (2006, September 22). Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Morbidity and Mortality Weekly Report, 55(RR14), 1-17. 6. Rockstroh J, Mocroft A, Soriano V et al. Influence of hepatitis C on HIV disease progression and response to highly active antiretroviral therapy. J Infect Dis 2005; 192: 992–1002 7. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. (2006 May 16). The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med, 144(10), 705-14.

Winter 2016

Hannah Tolley, MS, RNC-OB, CNL Labor and Delivery

Achievements

Congratulations to the following UMMC nurses promoted in 2015!

Shoshana Yudkowsky, BSN, RN, CCTN Transplant Intermediate Care Unit

Professional Advancement Model

Roberta Harvey-Correa, BSN, RN, CRN Radiology

Richard Bell, BSN, RN, CCRN-CSC University of Maryland eCare

Ashley Hernandez, BSN, RN Psychiatric Emergency Services

Samantha Dayberry, BSN, RN, PCCN Multi Trauma Intermediate Care 6

Andrew Histand, BSN, RN-BC Behavioral Health

Jessica Farace, BSN, RN, PCCN Multi Trauma Intermediate Care 6

Clare Howard, BSN, CNOR Perioperative Services

Deborah Guzik, BSN, RNC-OB Labor and Delivery

Susan Huppmann, BSN, RN Cardiac Cath Lab

Martha Hoffman, BSN, RN, CNOR Perioperative Services

Maureen Jones, BSN, RN, CPN Pediatric Infusion and Testing Center

Kathleen Lee, BSN, RN, CNOR Trauma Operating Room

Lisa Chang, BSN, RN, CMSRN Orthopaedics

Laura Joseph, MSN, MBA-HCM, RN, CCRNCSC, CPPS Lung Rescue Unit

Cheryl Mack, MPA, BSN, RN Adult Emergency Department

Brooke Donlon, BSN, RN, CNOR Perioperative Services

April Joynes, BSN, RN, CNOR Trauma Operating Room

Janice Dryden, BSN, RN, CBC Pediatric Cardiac Cath Lab

Nimeet Kapoor, BSN, RN, CCRN, FCCS Medical Intensive Care Unit

Lynmarie Dudley, BSN, RN, BS, PCCN Multi Trauma Intermediate Care 6

Cathy Karska, BSN, RN, BMTCN Blood and Marrow Transplant

Lauren Espeso, BSN, RN, CCRN Cardiac Surgery Intensive Care Unit

Allison Lembo, BSN, RN Shock Trauma Acute Care

John Felarca, MSN, RN, CNOR Perioperative Services

Janet Loehwing, BSN, RN NeuroCare Acute

Sarah Fox, MSN, RNC Neonatal Intensive Care Unit

Jordan Mullaney, BSN, RN Shock Trauma Outpatient Pavilion

Whitney Fox, MS, RN Psychiatric Emergency Services

Jennifer Orloff, BSN, RN, CCRN, CEN Critical Care Resuscitation Unit

Rebekah Friedrich, BSN, RN, CCRN Surgical Intensive Care Unit

Hara Oyedeji, MSEd, MSN, RN Psychiatric Emergency Services

Annie Grace, BSN, RN, CPN Otorhinolaryngology Outpatient Clinic/ PICO

Sylvia Rose, BSN, RN, CEN Adult Emergency Department

Senior Clinical Nurse I Jennifer Arrington, MS, RN, CPN, CNL Pediatric Intensive Care Unit Monique Barrow, BSN, RN General Operating Room Christina Boord, BSN, RN, OCN Hematology/Oncology Sara Broumel, BSN, RN NeuroTrauma Intermediate Care Unit Rianamie Carter, BSN, RN, CCRN Medical Intensive Care Unit

Lindsey Gray, BSN, RN-BC Geriatric Psychology Christina Grow, BSN, RNC-NIC Neonatal Intensive Care Unit Laura Haines, BSN, RN, CPAN Perioperative Services Heidi Halterman, RN, AAS, CEN Trauma Resuscitation Unit

Meghan Schott, BSN, RN Adult Emergency Department Megan Smith, BSN, RN, OCN Hematology/Oncology Marlyn Soloman, MSN, RN-BC Child Psychology Lindsey Stanton, BSN, RN Trauma 6N Ashleigh Stronski, BSN, RN, CCRN NeuroTrauma Critical Care

Senior Clinical Nurse II

Rachel Maranzano, BSN, RN, CCRN Surgical Intensive Care Unit Jennifer Meyer, BSN, RN NeuroTrauma Critical Care Kristen Rouse, BSN, RN Perioperative Services Coty Smootz, MAT, MS, RN Shock Trauma Outpatient Pavilion Rebecca Stecher, BSN, RN, CCRN, FCCS Medical Intensive Care Unit Stephanie Szoch, RN, BSN, OCN Hematology/Oncology

Congratulations to the following nurses at UMMC for being selected as one of the 55 winners in Baltimore magazine’s 2016 “Excellence in Nursing” survey,

which attracted hundreds of nominations over the past nine months. The names of the winners, chosen by a panel of seven nurse advisors, will be published in the May issue of Baltimore magazine. Donna Audia, RN, HN-BC Integrative Care Team Jasmine Noronha, BSN, RN Pediatric Progressive Care Unit Christina Purificato, BSN, RN, CCRN Surgical Intensive Care Unit Chona Rizarri, BSN, RN, PCCN Cardiac Surgery Stepdown Unit continued on page 9.

news &views Achievements, continued from page 8. Congratulations to the group of Pediatric Intensive Care Unit nurses who had two posters accepted for presentation at the Northeast Pediatric Cardiology Nurses Association Annual Conference held in Washington, D.C. in October 2015.

Congratulations to Carmel McComiskey, DNP, CRNP, FAANP, FAAN, director, nurse

practitioners and physician assistants, for a chapter that she authored for the 2015 publication Lippincott Certification Review: Pediatric Acute Care Nurse Practitioner, 1st edition. The chapter is titled “Preparation for Practice: Interprofessional Practice: Certification, Licensure, Credentialing Documentation, Billing, and Coding.”

The posters, “Thinking Outside the Heart: Pediatric Cardiac Surgery PostOperative Complications and ALCAPA,” and “Left Ventricular Dysfunction: A Pediatric Case Study,” were developed based on the nurses’ experiences of caring for post-operative pediatric cardiac surgery patients.

Congratulations to Jim Reiter, BSN, RN,

Left to right: Susie Park, MS, RN, CNII Colleen Ruoff, BSN, RN, CNII Melanie Hershberger, BSN, RN, CPN, CNII Katherine Spillman, MS, RN, CNII Diana Szekely, BSN, RN, CNII

senior clinical nurse I, on the Select Trauma IMC unit, who won the drawing for an Amazon.com gift card worth $100! The drawing was conducted as an incentive for UMMC nurses participating in survey research about the AskMe4 approach to patient education. The information gathered from this survey is being used to better understand the delivery of healthliterate teaching for patients in a way that nurses find useful. Look for the next opportunity to participate in this survey during Nurses Week in May!

Lauren Manrai, RN, CCRN, CNII Jennifer Arrington, MS, RN, CPN, CNL, SCNI Sarah Keaney, BSN, RN, CNII Other contributor not pictured: Jessica Masters, BSN, RN, CNII

Professional Advancement Model The Professional Advancement Model is designed to recognize and reward nurses based on their professional contributions to advancing the practice and profession of nursing. The model focuses on the continuing professional growth and development of the nurse with emphasis on involvement at the unit level, and contributions within the Medical Center and beyond.

Advancement requires the nurse to meet defined criteria related to clinical practice/care delivery, professional development, quality/safety, and unit operations. The 2016 Professional Advancement Model timeline is finalized (see below). For more information or to ask any questions, please contact Erin Barnaba at erinbarnaba@umm.edu.

Professional Advancement Model

2016 Timeline Submission of Applications

Review Team Meetings (review of applications)

Meetings with Interview Team (if necessary)

Release of Outcomes to Managers

Effective Date of Promotions

January 4 – 15

January 27 & 28 (9 am to 12 pm) Weinberg 6 conference room

February 4 (9 am to 12 pm) G8J25

February 19

February 21

April l – 15

April 27 & 28 (9 am to 12 pm) Weinberg 6 conference room

May 5 (9 am to 12 pm) Weinberg Learning Center 6/7

May 13

May 15

July 1 – 15

July 27 & 28 (9 am to 12 pm) Weinberg 6 conference room

August 4 (9 am to 12 pm) Weinberg Learning Center 6/7

August 19

August 21

October 3 – 14

October 26 & 27 (9 am to 12 pm) Weinberg 6 conference room

November 3 (9 am to 12 pm) Weinberg Learning Center 6/7

November 11

November 13

Winter 2016

It’s Alarming! Summary of Alarm Identification and Response Simulation (AIRS) Study Jamie Tumulty, MS, CRNP; Patricia Woltz, PhD, RN; Matt Rietschel, MS; Lynnee Roane, MS, RN, CCRP; Paul Thurman, MS, PhD(c), ACNPC, CCNS, CCRN; and Lisa Rowen, DNSc, RN, CENP, FAAN

Background – Significance – Purpose: Alarm fatigue or desensitization due to frequent and excessive alarms is a patient safety issue. When experienced UMMC nurses noted that newly graduated nurses hired into the intensive care units (ICUs) were responding poorly to clinical alarms, research was proposed to learn more about alarm responsiveness at the earliest stage, namely alarm recognition. The aim of the study was to discover how newly graduated ICU nurses best learn to recognize and respond to alarms. Methods The nurses completed a web-based simulation assessment with active listening and multiple selection components. The assessment consisted of 20 recordings with one to four alarms per recording; each followed by two multiple choice questions to identify all alarms and all the appropriate responses. The recordings consist of clinical alarms recorded in their natural milieu (i.e., in ICUs with background noise). Recordings were randomly reordered for each test. Experienced nurses tested the instrument, which demonstrated good validity (CVI = .80) and good to fair reliability (test-retest г = .71; IRR Cohen к = .26). Then, a randomized controlled trial was conducted in which 36 newly graduated nurses who were beginning usual ICU or intermediate care unit (IMC) orientation, consented to participate. Participants were randomly assigned to one of three groups. Nurses in the control group (Group 1) underwent simulation testing at the start and end of the 14-week ICU orientation. Group 2 nurses underwent simulation testing at five different times during the same time period (i.e., weeks 0,

4, 6, 10, and 14). Group 3 nurses underwent repeated testing like Group 2 and attended post-test classes given by a nurse practitioner. Classes consisted of an instructor-led review of alarms and responses along with a handout of mnemonics describing the alarms. All participants received compensation for their participation. Test results by group were analyzed for accuracy (test score) and responsiveness (test time) using repeated measures linear mixed models. Results Thirty-four nurses completed the study. One participant dropped out after signing an informed consent and gave no reason (Group 2); and, the other dropped out after the first study assessment stating that she felt too overwhelmed with her job to continue participation (Group 3). Both were removed from analysis. The sample was primarily female (91%), Caucasian (77%), worked on an ICU vs. an IMC (86%), worked with adults vs. pediatrics (69%), had a bachelor’s vs. an associate’s or clinical nurse leadership degree in nursing (77%), did not have prior formal musical training (57%), and had some sort of previous ICU work experience (71%). None of these characteristics or age (M = 27 years, SD 4.7) varied by group. For the entire sample, the mean test score and test time was 54 (SD 14) percent correct and 712 (178) seconds at baseline and 81 (SD 13) percent correct and 736 (SD 349) seconds at week 14. Although test scores for all groups improved with time (Figure 1), the growth curve for Group 3 was better than that of controls (β = -3.99, ρ = .001). There was no difference between the growth curves for groups 2 and 3. And although growth curves did not differ for groups 2 and 1, there was a trend toward difference (β = -2.46, ρ = .066). The best model controlled for an interaction of baseline score with time, indicating that the lower the score at baseline, the more likely it was to improve over time (β = -0.13, ρ = .001). Test time data showed wide variation and no differences by group were found. The performance of the test instrument itself was examined using test scores and found to be good for internal consistency (Cronbach’s α = .87) as well continued on page 11.

Figure 1: Simulation test scores by group after controlling for baseline scores

news &views AIRS Study,

continued from page 10.

as for sound-response pairs (Spearman-Brown split half г = .98). Double-blind observation in the clinical ICU setting of a randomly selected subset of participants from each group supported that simulation-based learning in this study translated to alarmresponsive behavior; however, the assessment was qualitative and could not be statistically analyzed. Despite best efforts to keep participants engaged during the study, Group 2 nurses missed the most scheduled testing sessions. Specifically, group 2 nurses missed 25% of study assessments compared to 0% and < 2% missed assessments for groups 1 and 3 nurses, respectively. Discussion These findings suggest that incorporating active listening simulation training, especially when supported with one-on-one review of alarms during new graduate nurse orientation, can improve new nurses’ ability to identify and respond to alarms in the ICU. Moreover, despite a greater time commitment, study participation suggests that nurses who receive one-on-one training are more engaged in learning than those who receive

Certification Corner

only simulation training. Limitations of this research were the introduction of new alarms on some of the units during the study and the inclusion of IMC nurses, who were exposed to fewer alarms (e.g., ventilator alarms) than the ICU nurses. More research is needed to understand the sustained effect of alarm recognition training on alarm response, as well as the impact of simulation-based alarm learning on patient safety. As UMMC more broadly addresses the impact of alarm fatigue on alarm response and patient safety, research such as this provides evidence for educational approaches in the novice nurse demographic. Acknowledgements We are deeply appreciative of the nurses, both experienced and inexperienced, who helped in this study. The study was funded in part by a grant from the American Association of Critical Care Nurses.

Certification is one way for employers to understand the employees’ level of competency, as well (Rauen, Shumate, Jacobson, Marzlin & Webner, 2014). Why Certification Certification rates have been linked Matters to increased retention rates, making them financially advantageous for orgaDennis Brumbles, MSN, NE-BC, RN-BC nizations. In a study of 29 ICU settings, Gallagher and Blegen (2010) identified Specialty certification signifies that a that there was an inverse proportion of nurse has advanced from an entry level of licensure to a level of specialty knowledge fall rates and required nursing care hours when the nurses held specialty certifica(Wilkerson, 2011). It has been speculated tion. Additionally, there is evidence that that certified nurses reduce medical certified oncological nurses give improved costs and contribute to positive patient care over their non-certified colleagues outcomes (Wade, 2012). Additionally, (Coleman, et al., 2009). certification has been identified as a “commitment to excellence,” resulting in Nursing certification can help higher standards of care and better patient empower individual nurses to pursue outcomes (Drenkard, 2013). Positive the next level in their careers. It is a evidence of nurse certification is well confidence-booster, as well as a source of documented in the literature. personal and professional pride. Clinical leaders and nurse managers, as well as Magnet organizations promote front-line staff who share a concern for certification as a component of patient care, should promote specialty professional practice. Indeed, nurse certification to all employees, particularly empowerment has been positively those interested in pursuing advanced associated with certification status levels of the clinical ladder. (McLaughlin and Fetzer, 2015). These The evidence is overwhelming with organizations are expected to demonstrate regard to the benefits of hiring certified a commitment to setting goals for applicants and encouraging certification certification (Bell-Kotwall and Kuiper, among existing staff. As we look ahead 2012). While it demonstrates high to our next Magnet re-designation, levels of expertise, a culture must be advancing our certification numbers promoted that supports certification is a priority within the organization. (Rees, et al. 2014).

We urge all managers to identify key stakeholders from within their staff and have them get involved in the Medical Center’s certification sub-committee. References Bell-Kotwall, L., Frierson, D., Kuiper, R. (2012). Are certified nurses better professionals? Nursing Management, 43(6), 30-35. doi: 10.1097/01.NUMA. 0000413641.52774.2c Coleman, E.A., Elizabeth A., Coon, S., Lockhart, K., Kennedy, Robert L., Montgomery, R., Copeland, N., McNatt, P., Savell, S., Stewart, C. Effect of certification in oncology nursing on nursing sensitive outcomes. Clinical Journal of Oncology Nursing, 13(2). Retrieved from: http://www.onsmetapress.com. Drenkard, K. (2013). Credentialing as a commitment to excellence. Journal of Nursing Administration, 43(3), 119-121. doi: 10.1097/NNA.0b013e318283db48 Gallagher, D.K. & Blegen, M.A. (2009). Competence and certification of registered nurses and safety of patients in ICU. American Journal of Critical Care, 18(2), 106-118. McLaughlin, A. & Fetzer, S. (2015). The perceived value of certification by Magnet® and non-Magnet nurses. JONA, 45(4), 194-199. doi: 10.1097/ NNA.0000000000000184 Rauen, C., Shumate, P., Jacobson, C., Marzlin, K., & Webner, C. (2014). “To know”: A great reason for certification. CriticalCareNurse, 34(1), 66. doi:10.4037/ ccn2014924 Rees, S., Glynn, M., Moore, R., Rankin, Stevens, L. (2014). Supporting nurse manager certification. JONA, 44(6), 368-371. doi: 10.1097/NNA.0000000000000083 Wade, C. (2012). Relationships among specialty certification in nursing role breadth self-efficacy, and nurses’ use of proactive work behaviors. (Dissertation). Retrieved from: http://search.proquest. com/docview/1019235412 Wilkerson, B. (2011). Specialty nurse certification affects patient outcomes. Plastic Surgical Nursing, 31(2), 57-59.

Winter 2016

Pain Improvement Initiative to Increase Patient Pain Satisfaction Gena Stiver Stanek, MS, APRN-CNS, CNS-BC, Clinical Practice and Development Coordinator and Scott A. Taylor, DNP, CRNP, Clinical Practice and Development Coordinator

Achieving high patient satisfaction in relation to pain is a major priority for the University of Maryland Medical Center (UMMC). In the beginning of FY 2015, pain satisfaction scores were below the 50th percentile according to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) which caused great concern. HCAHPS is a survey that evaluates the patients’ perspective on their recent hospitalization (CMS, 2016). Two questions on this survey focus on pain. One asks patients if their pain was well controlled, and the second, if staff did everything they could to help their pain (HCAHPS, 2016). Ideally, patient satisfaction should be above the 80th percentile ranking. Therefore, implementing a strategy to improve this rating was recognized by the Pain Improvement Team. This article will focus on the stakeholders and interventions used in an attempt to increase patient pain satisfaction at UMMC. The Pain Improvement Team is a subcommittee of the UMMC Clinical Practice Council. This group implemented a strategy in an attempt to improve the hospital HCAHPS score related to pain management. The membership consists of nurses from several units within the hospital who focus on educating staff in an effort to improve pain awareness and treatment. This group also tracks Figure 1: How to use on-demand videos

the hospital’s HCAHPS scores and looks for ways to improve the delivery of pain management within UMMC. With scores being below the 50th percentile, the Pain Improvement Team’s goal was to develop a strategy to improve the HCAHPS scores related to pain management. This strategy included the development of a process improvement project that focused on the utilization of the video on-demand system and the C.A.R.E.® channel (40 on patient TV). The purpose of this project was to increase usage of the video on-demand system and the C.A.R.E. ® channel with an expected outcome that patient pain satisfaction would improve. This initiative began in January of 2015 using a multi-pronged approach that emphasized utilizing pain management education videos, relaxation-guided imagery videos and the relaxation

C.A.R.E.® channel. The purpose of the education videos was to educate patients about their pain and the steps that can be taken in the management of their pain. The video also reviews resources available at UMMC for the management of pain. The C.A.R.E.® channel provides general relaxation 24/7, with music and nature images during the day and a star-filled night sky during the hours of 10:00 pm to 6:00 am. The 28 relaxationguided imagery videos focus on general relaxation; special needs such as heart wellness, preparing to give birth, and post trauma; children’s needs, such as children with cancer and naptime; and, nighttime programs for sleep and rest, such as evening tranquility. The River is a guided imagery video that focuses specifically on diminishing pain. These videos can be assigned to the patient and played as appropriate anytime throughout the day. An investigational study conducted in 2010 noted patients who utilized guided imagery had less post-operative pain and had decreased length of stay in the recovery area (Gonzalez, Ledesma, McAlister, Perry, Dyer, and Maye, 2010). Dissemination of the project plan was conducted using the graphics package PowerPoint which focused on the project purpose, baseline data, proposed interventions, and implementation methods. The plan was presented to nurses by members of the Pain Improvement Team that served as project champions. The content included educating the staff on video resources available, use of the video system and the C.A.R.E.® channel, and identifying patient/family educational needs. This project also focused on teaching patients/families to utilize the video system and the C.A.R.E.® channel and encouraged staff to utilize on-demand videos in clinical practice on a consistent basis. (See Figure 1) To further promote this project, the Pain Improvement Team collaborated with the Integrative Care Team at UMMC to promote the use of guided imagery videos to the patients that they serve. The project was also shared with several of the nursing shared governance councils at UMMC with the goal of their representatives to disseminate this information at the unit level. The Pain Improvement Team also worked closely with the Patient Education Council and On-Demand Subgroup in the promotion continued on page 13. of this project.

news &views Pain Improvement Initiative, continued from page 12. 50

35 Pain Satisfaction

Percentile

Pain Controlled Staff Doing Everything

References “Centers for Medicare/Medicaid Service.” accessed January 7, 2015. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessmentinstruments/HospitalQualityInits/HospitalHCAHPS.html “Hospital Consumer Assessment of Healthcare Providers & Systems.” accessed January 7, 2015. http://www.hcahpsonline.org/files/HCAHPS%20V10.0%20Appendix%20 A%20-%20HCAHPS%20Mail%20Survey%20Materials%20(English)%20 March%202015.pdf Gonzales, E.A., Ledesma, R.J.A, McAllister, D.J., Perry, S.M., Dyer, C.A., Maye, J.P. (2010). Effects of guided imagery on postoperative outcomes in patient undergoing same-day surgical procedures: A randomized, single-blinded study. American Association of Nurse Anesthetists Journal, 78(3), 181-188.

0 Jul-Sept 14

Oct-Dec 14

Jan-Mar 15* Quarter

*Implementation month

Apr-Jun 15

Jul-Sept **

** Note new measurement system

Figure 2: Patient Pain Satisfaction Data

Pre- and post-implementation results were compared in May of 2015 to determine the effectiveness of the intervention. The quarter when this project was implemented showed an increase in patient pain satisfaction and video usage. (See Figures 2 & 3). Subsequent quarters continue to show improvements in video usage in comparison to the pre-implementation data; however, the pain satisfaction scores are not increasing, indicating more work is needed to achieve higher patient satisfaction pain scores. UMMC also changed patient satisfaction vendors in July 2015 causing a transition period with the survey process. Due to this change, it will be necessary to wait for several quarters of data to re-establish a baseline for this project. Based on these outcomes, the Pain Improvement Team will continue to work diligently to assist staff at UMMC to improve patient pain satisfaction. The team encourages all nurses to be advocates for patients with regard to managing their pain. Patient assessment, utilization of pharmacologic, as well as non-pharmacologic resources, is vital in treating pain. Figure 4 highlights efforts that all nurses can utilize to help increase patient pain satisfaction. Please contact Gena Stanek at gstanek@umm.edu or Scott Taylor at staylor3@umm.edu if you have any questions or need further assistance implementing these initiatives on your unit.

Video Topic Average Monthly Usage

Jul-Sept 14

Pre Implementation Oct-Dec 14

Implementation Jan-Mar 15

Apr-Jun 15

Your Care/Speak Up

134

127

Guided Imagery

N/A

Pain

Figure 3

Strategy

Action

Obtain a pain assessment.

OPQRSTU

Educate your patient on pain management.

Show patient “Your Care-Speak Up” video on admission (introduces pain management). Introduce and show pain and relaxation guided imagery videos; use the C.A.R.E.® channel (40 on patient TV).

Ask specific questions about the patient’s pain.

Tell me about your pain? Is your pain better or worse? How would you rate your pain now? What has helped with pain in the past? We want to do everything we can to minimize your pain.

Advocate for the patient during daily rounds.

If pain not controlled, ask the provider to reevaluate the pain management plan. Recommend pain consult.

Patient/Family Education

Educate the patient/family on the pain plan, as well as side effects of the interventions.

Patient role for managing pain

Watch the pain education and relaxation videos. Report pain and side effects to your nurse. Take an active role in their pain management.

Consider non-pharmacological/alternative interventions for pain management.

Integrative medicine consult. Deep breathing/relaxation/dim lights/C.A.R.E. ® channel.

Figure 4

Winter 2016

ADVANCED PRACTICE NURSING

Quality of Life after the Intensive Care Unit (ICU) Tracey Wilson, DNP, ACNP and Kim Bowers, MS, ACNP Medical ICU Acute Care Nurse Practitioners

Background

Nearly five million patients are admitted to the ICU each year, with at least four million survivors.1 With advancements in technology and medicine, the survival rate from a critical illness has grown tremendously. Although patient survival rates have been optimized, health care providers need to ask about overall outcomes. One outcome of particular interest develops after discharge. Patients and families are confronted with a new-emerging issue after the critical care event known as Post Intensive Care Syndrome (PICS). Up to 80% of patients and 40% of family members develop some component of PICS.2 Ultimately, patients and families experience a decrease in quality of life and become unable to fully engage in health care needs post discharge. What is PICS? It is a response to a critical illness. It affects cognitive, physical, and mental health. The syndrome contains a cluster of adverse psychological disorders, including depression, complicated grief, post-traumatic stress disorder, anxiety, and acute stress disorder.2 PICS can affect patients and families for up to one year and beyond.2 This is an all-encompassing health problem that has been overlooked in the past but is quickly gaining recognition. It has always been assumed that an ICU stay impacts long-term recovery but health care providers now understand that it can be devastating and often prolonged. Through awareness and education, both critical care and noncritical care nurses and advanced practice nurses (APNs) have the ability to minimize the development of PICS and improve outcomes. The role of the APN in PICS includes staff education, prevention of PICS, recognition and intervention of identified risk factors, and management of symptoms after the stay in the ICU. Risk Factors and Interventions Identified risk factors include age over 65, ICU length of stay (LOS), family unable to visit, sepsis, hypoxia, immobility, pain, agitation, use of sedatives, delirium, poor nutrition, and poorly controlled glucose levels.3,4 Of note, consider how common these findings are in any ICU setting. There are several associated interventions that provide the best physical, psychological, cognitive, and functional recovery. Maintaining a lower level of sedation, minimizing nutrition interruptions, avoiding hypoglycemia and shifts in glucose, early mobilization, and reducing the use of benzodiazepines may contribute to the prevention of PICS.4 There are national guidelines for many of these associated interventions. Health care providers should understand the guidelines and plan to integrate these into

practice. One essential aspect of the scope of APN practice includes implementation of research to provide high-quality health care, initiate change, and improve nursing practice.5 Post-care Interventions Many health care providers are unaware of this syndrome. Though the patients survive their ICU stay, they have lost their quality of life, their ability to work, and other important aspects of their daily life.4 Health care providers need to recognize the significance of these symptoms.3 PICS is far more debilitating than depression and anxiety. PICS is a complex syndrome that will continue to alter the former patient’s quality of life; some have reported symptoms lasting as long as four years. Just as health care is recognized as a continuum, health care providers must understand that surviving the inpatient stay does not end the devastating effects of the illness. Patients and their family members need ongoing psychosocial support. Development of some component of PICS after ICU stay

PATIENTS

FAMILY MEMBERS

80%

40%

PICS and Impact on Family The Society of Critical Care Medicine Task Force defined the term PICS-F in 2010.2 As mentioned, both patients and family members are at risk for developing PICS. The risk factors for the family include the following: ◗◗ female; ◗◗ lower socio-economic class; ◗◗ single parent of a child in critical care; ◗◗ previous ICU experience, especially death or near death event; ◗◗ long distance from facility; ◗◗ perceived ineffective communication from ICU staff; ◗◗ pre-existing anxiety; ◗◗ current weak support system; and ◗◗ unaware of patient’s wishes.2 Similar to caring for the patient, interventions exist to help prevent or minimize PICS-F. One of the most identified areas needing improvement surrounds communication. Family members should receive frequent updates in a language that they can understand.6 Communication needs to be consistent. Use of a valid tool, such as the VALUE method, has been shown to be effective. VALUE stands for value what is being said, acknowledge, listen to the family, understand, and elicit continued on page 15.

news &views The RISE Program Goes Live at UMMC Gena Stiver Stanek, MS, APRN-CNS, CNS-BC, Clinical Practice and Development Coordinator and Precious Grant, BA, Project Specialist

The RISE (Resilience in Stressful Environment) program was implemented at UMMC in August 2015, after nearly a year of preparation. The program provides 24/7 peer support to health care workers who are “second victims,” a term used to describe health care workers involved in adverse events and/or who have encountered stressful, patient-related events. The program’s objectives include: increasing awareness of the “second victim,” providing peer support in a non-judgmental environment, reassuring as well as guiding employees to continue to thrive in their professional roles, and equipping managers and employees with healthy coping strategies. Medical Center leaders are highly supportive of the RISE program as they understand how challenging situations and unintentional events routinely happen in health care settings. We want staff to feel supported, experience high morale, and provide excellent patient care. The three main components that separate RISE from other programs are peer-to-peer support, immediate assistance, and non-judgmental, confidential support. Two surveys conducted in 2011 and 2013 found that after a particularly difficult clinical situation, employees had a harder time performing their job functions, had increased anxiety and/ or depression, and nightmares. The survey also concluded that some employees believe there is a “blame culture” at UMMC. Our goal is to dispel that belief, as having a “blame-free” culture is essential for providing quality care. Those selected as RISE responders are highly functioning adults who have effective coping skills prior to an event. Interested responders apply, go through an interview process and, once accepted, attend RISE education. RISE faculty at Johns Hopkins Hospital (where the program started) provides responder education. This training describes peer support and the need for, and value of, a peer-support program, applies the principles and skills of peer support, provides supportive strategies for the peer responder team, compares 1-on-1 peer support, as well as group support, and identifies situations that fall outside of RISE’s scope.

Since the RISE program went live last August, RISE responders have successfully responded to two calls, and 24 responders have been trained. The RISE responder is responsible for the following: ◗◗ Respond to caller ASAP (5-10 minutes). ◗◗ Schedule a 1-on-1 meeting. During the meeting the responder has the following responsibilities: • Introduce oneself and allow the individual to discuss anything he/she would like; • LISTEN, LISTEN, LISTEN; • “Normalize” negative emotions; • Review how he/she is coping; • Refer to additional resources as appropriate; and • Schedule follow-up meeting, if needed. RISE program responders are on call 24/7, 365 days per year and can be reached by using the hospital paging system, ID # 12602 or simply typing “RISE” under “Function Name” on the INSIDER pager web page. From outside the hospital, dial 410-328-2337, ID # 12602 and follow the instructions. The next implementation phase will focus on re-education to ensure staff knows when to use the program and how to contact a peer responder. We hope staff will become more aware of the program and feel comfortable using it. RISE executive sponsors are Lisa Rowen, DNSc, RN, CENP, FAAN, senior vice president of patient care services and chief nursing officer and Ingrid Connerney, DrPH, RN, CPPS, senior director, quality, safety and clinical effectiveness. Co-leading the program are Gena Stiver Stanek, MS, APRN-CNS, CNS-BC, and Rabbi Ruth Smith. Precious Grant, BA, provides project specialist support, and Phyllis Shirk, MA, provides administrative support. If you have questions, please contact Gena Stanek at gstanek@ umm.edu or Rabbi Ruth Smith at rsmith5@umm.edu.

Quality of Life After the ICU, continued from page 14. information.6 Family education should be presented in a variety of formats, such as verbal, written, and by video. Conclusion Success in minimizing the development of PICS depends on vigilant nursing care. Nurses and providers should teach patients and families, and adhere to the guidelines for prevention of PICS. Nurses and advanced practice nurses can be instrumental in not only delivering high quality critical care to patients, but also optimizing their lives after the intensive care unit. Health care providers should be aware of this devastating syndrome and recognize symptoms in order to provide appropriate care for the patient and family.

References 1. Society of Critical Care Medicine (n.d.). Critical Care Statistics. Retrieved February 27, 2014, from http://www.sccm.org 2. Davidson, J. E., Jones, C., & Bienvena, O. J. (2012). Family response to critical illness: Post intensive care syndrome-family. Critical Care Medicine, 40(2), 618-624. 3. Needham, D. M., Davidson, J., Cohen, H., Hopkins, R. O., Weinert, C., Wunsch, H.,... Brady, S. L. (2012). Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholder’s conference. Critical Care Medicine, 40(2), 502-509. 4. Harvey, M. A., & Davidson, J. (2011). Long-term consequences of critical illness: A new opportunity for high-impact critical care nurses. Critical Care Nurse, 31(5), 1-4. 5. American Association of Colleges of Nursing (n.d.). The essentials of master’s education for advanced practice nursing. Retrieved December 16, 2015, from http:// http://www.aacn.nche.edu/education-resources/MasEssentials96.pdf 6. Curtis, J. R., Ciechanowski, P. S., Downey, L., Gold, J., Nielsen, E. L., Shannon, S. E.,...Engelberg, R. A. (2012). Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU. Contemporary Clinical Trials, 33(6), 1245-1254.

Winter 2016

Journal Club

“Effects of Nursing Position on Transformational Leadership Practices” Authors: Susan Herman, DNP, RN, NEA-BC, CENP; Mary Gish, DNP, RN, NEA-BC; and Ruth Rosenblum, DNP, RN, PNP-BC Lisa Petty, BSN, RN, CCRN, HNB-BC Senior Clinical Nurse I Mobile Practitioner/Rapid Response Team

Background The Journal Club reviewed the above transformational leadership article, including the discussion of the cited study. The purpose of the study was to identify significant differences in nursing leadership strengths by position titles.

Health care is constantly changing. Nurse leadership is essential in meeting the changing demands in health care and in creating an environment supportive of optimizing patient outcomes, quality of care, and staff development. Collaboration, emotional intelligence, education, positive organizational climate, professional development, and positive leadership are characteristics that optimize patient and staff outcomes (Pearson et al., 2007). The 2011, Institute of Medicine report, “The Future of Nursing,” emphasized that nurses must become transformational leaders to assist in changing the health care environment, creating a vision for the future, and engaging others in this important endeavor. Review

In this article reviewed for Journal Club, the authors used the transformational leadership (TL) theoretical framework which distinguishes between transactional leaders and transformational leaders to guide their investigation (Burns, 1978). In developing this framework, Burns observed that relations between leaders and followers were mainly transactional and less effective than relations that were fostered by transformational leaders. A transactional leader exchanged values

one-to-one, whereas a transformational leader created a mutually beneficial relationship between leader and follower, reaching higher, more favorable goals and visions. Research by Kouzes and Posner (1999) supported Burns’ theoretical framework. They observed that leaders engage in five exemplary practices; Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart. Kouzes and Posner (1999) also supported the need for continual learning and development in all levels of leadership. Subsequently, they developed the Leadership Practices Inventory – self-assessment (LPI-S) to measure these nurse leadership competencies. Using the tools previously developed by Burns (1978) and Kouzes & Posner (1999), the authors of this article examined the TL practices and behaviors of nurse leaders with respect to management. The study sample included members of the Association of California Nurse Leaders (ACNL). They provide a good representation of nursing leadership with nurses ranging in education from diploma to doctorate. Their leadership roles spanned the spectrum from charge nurse to chief executive officer. The survey was sent to over one thousand members of ACNL who were asked to complete and return the survey. Only 261 (22%) of those invited responded to the survey. Using the LPI-S, good internal consistency showed statistically sufficient measure of comparisons of ACNL demographic groups with a Cronbach’s α value of .75 to .87, and the entire respondent data resulting in a Cronbach’s α of .94. LPI-S scores showed leadership practices at different levels of management were statistically

differentiated. The chief nursing officer (CNO) group had the strongest selfratings for two practices of TL, Enable Others to Act and Model the Way. No significant differences were found between the CNO and director level in all five practices of TL. There was a statistically significant difference in the TL practices between participants at the level of director and above compared to those who were at the level of manager and below. Overall, the highest ratings were for the practice Enable Others to Act and the lowest ratings were for Challenge the Process and Inspire a Shared Vision. The lowest scores indicate the need for further development in leadership and all nurses may benefit from ongoing leadership training. Bias is a potential limitation of the study. Those who responded to the survey may have felt more strongly about leadership than those who decided not to participate. The survey was administered anonymously, making it impossible to verify or confirm the accuracy of the information. However, because it was confidential, there would be no reason to intentionally mislead the researchers. So, the data was felt to have good representation of nursing leadership. This study contributes to nursing knowledge by describing the gap in practices of TL. The findings can be utilized by nursing administration to shape education and training for leadership development, with a specific focus on improving the practices of TL. TL is not a new approach to nursing, but one that is long overdue. It focuses on motivation, coaching, inspiring, and transforming others. It is a teamwork approach with a common vision of accomplishing goals using open communication and transparency. continued on page 17.

news &views Journal Club,

continued from page 16.

TL and UMMC

Discussion Points

Transformational leaders can help to guide others to create effective solutions to today’s health care problems. UMMC is a Magnet® hospital and one of the core requirements of Magnet® is transformational leadership (see Figure 1). This is supported by our Professional Practice Model under Leadership and Governance (see Figure 2). Transformational leadership has five different aspects that can be learned and integrated into everyday nursing at all levels. Focusing on the gaps and providing specific training will enhance leadership ability which is vital in supporting today’s health care environment. Nurses must be encouraged to get involved in advocating for needed changes and improving standards of care. Ultimately, this will benefit staff, the overall climate of the organization and, most importantly, the patients and families in our community.

◗◗ Health care presents many challenges and creating a supportive environment is of utmost importance for best possible outcomes. ◗◗ The Institute of Medicine (IOM) and the American Nurses Credentialing Center (ANCC) are leading the change in TL. As a Magnet® hospital, UMMC works diligently to strengthen their position in this area of professional development. ◗◗ The findings regarding the differences in position titles could help to shape leadership development at UMMC. ◗◗ All nurses can and should be leaders as well as learn TL practices. The Professional Advancement Council is looking at ways to incorporate TL into the Professional Advancement Model.

Figure 1: Magnet® Model References Burns, J. (1978). Leadership. New York: Harper & Row Publishers, NY. Institute of Medicine of the National Academies. (2011). The future of nursing: Leading change, advancing health. Washington, DC. The National Academies Press. Kouzes, J. & Posner, B. (1999). Leadership Practices Inventory-Self. 4th edition. San Francisco, CA. Pearson, A., Lashinger, H., Porrit, K., Jordan, Z., Tucker, D., Long, L. (2007). Comprehensive systematic review of evidence on developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. International Journal of Evidence Based Healthcare, 5, 208-253

Professional Standards (Yellow) ANA Scope & Standards, Maryland Nurse Practice Act, professional organizational standards, regulatory standards, ethical standards Patient Care Delivery (Blue) Relationship Based Care; Care Delivery across the Continuum; Evidence Based Practice Excellent and Safe Patient/Family Care Leadership and Governance (Red) Transformational leaders; shared governance structures Professional Values (Orange) Commitment to Excellence, UMMC Behavioral Standards, interprofessional collaboration, educational partnerships (UMNursing), community partnerships, healthy work environment Advancement of Nursing Practice (Green) Clinical inquiry (research, EBP and QI), professional advancement model, certifications, continuing education

Figure 2: UMMC Nursing Professional Practice Model

Winter 2016

Core Measures

The Newest Core Measure Set – Severe Sepsis/Septic Shock Sylvia Daniels, BSN, RN, Manager, Regulatory Compliance and Outcomes Management Crystal Evans, BSN, RN, Senior Core Measures Coordinator

In October 2015, the Medical Center, like other hospitals in the U.S., began to abstract data for the severe sepsis core measure. This is a Centers for Medicare and Medicaid Services (CMS) requirement for all hospitals participating in inpatient quality reporting. Although hospitals in Maryland are exempt from CMS reporting requirements, the Maryland Healthcare Commission has decided that quality reporting requirements for Maryland hospitals will mirror those of CMS.

Treatment guidelines for severe sepsis and septic shock are consistent with the surviving sepsis campaign guidelines (Dellinger, Levy, Rhodes, 2012). This measure assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. The administration of the treatment for severe sepsis and/or septic shock is very time sensitive: The following must be documented as received within three hours of the presentation of severe sepsis: 1. Initial lactate level measurement; 2. Broad spectrum or other antibiotics administered, AND 3. Blood cultures drawn prior to antibiotics. AND ONLY IF septic shock is present: Resuscitation with 30 ml/kg crystalloid fluids within three hours of presentation of septic shock. The following must be documented as received within six hours of presentation of severe sepsis: 1. Repeat lactate level measurement only if initial lactate level was > 2.

This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. To determine the presence of either one or both of these conditions, a AND ONLY IF hypotension persists after fluid administration: patient’s record is screened using the criteria below, or there is documentation of severe sepsis or septic shock by the physician, Vasopressors within six hours of presentation of septic shock. advanced practice nurse (APN), or physician assistant (PA). AND ONLY IF hypotension persists after fluid administration or initial lactate >= 4 mmol/L: Repeat volume status and tissue For severe sepsis to be present, ALL of the following perfusion assessment. must be met: The Medical Center’s strategy for ensuring compliance with 1. Documentation of suspected source of clinical infection; 2. SIRS criteria (2 or more of the following): (SIRS = Systemic the severe sepsis/septic shock treatment guidelines is to focus on education of physicians, advanced practice nurses (APNs), Inflammatory Response Syndrome); physician assistants (PAs), and nurses. The education plan includes • temperature ≥ 38.0°C (101°F) or ≤ 36°C (96.9°F); all services; however, efforts began with the two areas in which the • heart rate ≥ 90 beats per minute; majority of these patients are diagnosed – the adult emergency • respiratory rate ≥ 20 breaths per minute; or department (AED) and the Medical Intensive Care Unit • WBC ≥ 12,000 or ≤ 4,000 or ≥ 10% bands. (MICU). Portfolio is being used whenever possible, to hard-wire 3. ORGAN dysfunction (any one of the following): the required treatment and documentation needed to show our • SBP < 90 or MAP < 65 or in SBP by > 40mm/Hg compliance with the severe sepsis and septic shock guidelines. from the last recorded SBP considered normal for The efforts to show excellent compliance with the given patient; treatment guidelines is a priority for both the Medical Center • creatinine > 2.0, or urine output < 0.5 mL/kg/hour and the Medical System. Several committees are in place to for 2 hours; provide oversight for severe sepsis improvement efforts: the • bilirubin > 2 mg/dL (34.2 mmol); UMMC Sepsis Committee; the AED Sepsis Committee; a • platelet count < 100,00; MICU sepsis workgroup; UMMC Portfolio sepsis workgroup • INR > 1.5 or aPTT > 60 sec; and the UMMS sepsis workgroup. The committees/workgroups • lactate > 2 mmol/L (18.0 mg/dL); or are multidisciplinary with representation from Medical Center • acute respiratory failure as evidenced by the need for leadership, intensivists, emergency department physicians, chief new invasive or non-invasive mechanical ventilation. residents, nursing, infection control, nurse practitioners, clinical For septic shock to be present, the following must be met: informatics, and staff from Regulatory and Compliance Affairs. 1. Documentation of severe sepsis, AND In the coming months, performance data will be shared 2. Lactate level is > = 4 mmol/L, OR for this measure and what efforts will be needed from each 3. Tissue hypo-perfusion persists after crystalloid fluid is discipline to help improve compliance with the severe sepsis/ administered (evidenced by one of the following): septic shock measure. • systolic blood pressure (SBP) < 90, or • mean arterial pressure < 65, or • decrease in SBP by > 40 mmHg from the last recorded SBP considered normal for given patient.

References Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637.

news &views R Adams Cowley Shock Trauma Center Violence Intervention Program Ruth Adeola, MS, RN, Violence & Injury Prevention Program Coordinator, R Adams Cowley Shock Trauma Center, Center for Injury Prevention & Policy

In the United States, violence is a significant problem. In 2013, approximately 16,121 people were victims of homicide.1 Almost a million youths between the ages of 15 to 24 years were treated for nonfatal violent injuries in 2006 and nearly 40% of the violently injured youths returned to the emergency department (ED) with violencerelated injuries. Within five years of admission, nearly 20% become victims of homicide.2 This cycle of violent injury creates an unnecessary financial burden on the health care system and society as a whole. VIP Background Carnell Cooper, MD, started the Violence Intervention Program (VIP) in 1998, after seeing victims of traumatic violent injury being treated, released and re-admitted months later due to another, often more serious, violent injury. Dr. Cooper lost count of how many times he had to “patch up” a victim of gunshot wounds in the Trauma Resuscitation Unit (TRU), only to have the patient come back months later. One night in 1994, as he worked feverishly with the team to restart the heart of a young man cut down on Baltimore’s meanest streets, “I recognized him,” Dr. Cooper recalls. About six months earlier he had repaired the young man’s wounded abdomen. This time it was too late; the young man died. History Seeking to end the ‘revolving door’ phenomenon for victims of violence, Dr. Cooper started the Violence Intervention Program (VIP). The mission of the VIP is to prevent violent personal injury among Baltimore City’s most at-risk populations through research into the root causes of violence and to develop evidence-based primary and secondary prevention programs targeting this vulnerable population. Since its inception 17 years ago, the VIP has demonstrated time and again that bedside intervention of even the most violent offenders can and does make a difference in transforming damaged lives into productive ones. While secondary prevention through VIP has been impactful, the program recognized the need for primary prevention to stop interpersonal violence before it begins. My Future–My Career (MFMC), and Promoting Healthy Alternatives for Teens (PHAT) are the two on-site school programs offered by the VIP. This innovative violence prevention format is designed to engage youths who are at risk for either becoming victims and/ or victimizing others to focus on goals for the future, including higher education and careers. The Bridge Project is VIP’s domestic violence initiative to break the cycle of intimate partner and sexual violence. The program provides assessment, crisis intervention, advocacy, and counseling, along with referrals to the best resources in the community. The Impact of VIP – Transforming Lives The VIP model begins in the hospital and thrives in the community. This intensive hospital-based intervention program assists victims of intentional violent injury through bedside intervention,

assessment, counseling, and social support from a multidisciplinary team to help them make critical changes in their lives. The VIP works with other agencies in the community to provide a multidisciplinary, comprehensive, individualized re-entry action plan. Immediate and long-term change for the patient is facilitated by physicians, nurses, social workers, law enforcement, family, and community support. VIP activates community partnerships to keep those re-entering the community after discharge from the STC on the track of nonviolent and non-criminal behavior. Harvest for the Hungry & Spirit of the Season An essential part of the VIP services includes restoring feelings of dignity among the program participants. Each year, the VIP holds a Thanksgiving dinner for participants who would otherwise go without a meal or family with which to share the holiday. The program also collects non-perishable food items.

Left to right: Diana Macfarlane, MT (ASCP) and Nicolle Borys, MBA, MS, PA, MT

Participants and their families also had the privilege of being “adopted” by various clinical units and departments at UMMC during the holiday season. This year, eight families from the West Baltimore community were adopted. The VIP team was overwhelmed with the generosity of wrapped Christmas gifts from the Office of Clinical Practice and Professional Development, Lab/Pathology, Pharmacy, STC 6IMC, the Trauma Director’s office and VIP staff. The gifts provided support in both spirit and giving for the participants and their families during times of need, recognition, and celebration. References 1. Centers for Disease Control and Prevention (2015). Injury prevention and control: Division of Violence Prevention. Retrieved from http://www.cdc.gov/ violenceprevention/overview/ 2. Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Annals of Emergency Medicine 2009;53(4):490-500

Winter 2016

The Journey to Becoming a High Reliability Organization: The Science of Safety and the Power of Zero Deborah L. Schofield, DNP, CRNP, FAANP, Director, Patient Safety and Quality and Mangla Gulati, MD, CPPS, Vice President, Patient Safety and Clinical Effectiveness

Many in health care are familiar with the Institute of Medicine’s (IOM) original publication, “To Err is Human,”1 released in 1999. This seminal work highlighted the significant patient safety issues within our nation’s hospitals. The IOM estimated that preventable errors accounted for as many as 44,000 to 98,000 deaths per year for those in medical care in the U.S.1 By its estimate, more people died from medical errors than from AIDS, motor vehicle accidents, or breast cancer. The IOM report roused national quality and safety experts and the public around the issue of improving patient safety. Pursuant to the IOM revelations on patient safety and widespread errors within our nation’s hospitals, health care leaders began to seek solutions to establish patient safety as the primary objective for clinicians everywhere. This required a shift in focus, practice and approach to daily work.1 In spite of these efforts, a more recent report estimates preventable harm to between 220,000 and 440,000 per year.2 Health care leaders began to look to other high-risk industries for their perspectives, approaches, and solutions to achieving safe and reliable care for all patients. Industries such as aviation, nuclear power, hazardous chemicals, and aeronautics provide examples of complex organizations which experience fewer than typical accidents despite operating in “risky” environments.3 These are industries constantly at high risk of catastrophic events, yet have a much better safety record than health care. These industries became known as high-reliability organizations (HROs). How do these HROs achieve such outcomes while operating under such high-stakes conditions? 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).3 Is health care any different from the HROs? Health care is a very complex environment with non-stop activity, intricate interdisciplinary processes, operational 24 hours a day, seven days a week with patients and the health care provider central to the work. The health care team is not only made up of those individuals who provide the clinical care but also those who support the delivery of care from the point of access into the hospital and every step along the way. It is this collective

mindfulness that allows everyone to be acutely aware and empowered to speak up about anything that may lead to unsafe care. It is necessary to recognize that most health care clinicians did not learn about the science of safety in their professional education;3 many are unaware that patient safety is indeed a science for which specific principles are applied in order to best ensure optimal patient outcomes. In fact, for many, the science of safety is The Institute of Medicine’s original a concept and skillset learned publication, “To Err is Human,”1 released or acquired, in addition to in 1999, brought attention to the issue core clinical learnings – not of improving patient safety. as an integral part of their professional education. It is incumbent upon leadership and clinical leaders to understand and apply the science of safety to the daily work in their organization.3 So, what are the foundational principles of the science of safety and what can we do to improve? Since every system is perfectly designed to achieve the results it gets, it is important to understand the principles of safe design: standardization (consistent and correct use of checklists); learning when things go wrong; and application of these principles to technical work and teamwork, as teams make wise decisions when there is diverse and independent input. System design includes several factors that, together, influence unit culture and patient safety, including: patient characteristics (acuity, medical history, primary language, ability to participate in care); task-related factors (complexity of the task); and, individual provider characteristics (the relationship between specific knowledge base, skills and attitudes, and how these can affect the quality of care). For example, it is essential for all members of the team to feel comfortable speaking up when they identify any patient safety risks, such as a breach of protocol. Also, team factors (ability to work within teams effectively and effective communication) impact patient safety; work environmental factors (enhancing the environment by assuring clean, noise-free, well-lit areas); departmental factors (addressing staffing shortages which may cause an increase in medication errors or procedural errors); and institutional factors (such as budgetary limitations and characteristics of the facility) continued on page 22. all can affect the patient’s plan of care.4

news &views Mother/Baby Sleep Safe Pilot Innovations Gena Stiver Stanek, MS, APRN-CNS, CNS-BC, Clinical Practice Development Coordinator and clinical owner of the UMMC Video On-Demand Patient Education System

Despite being the wealthiest country in the world, the United States has a higher infant mortality rate than 25 other developed countries, according to a new report from the Centers for Disease Control and Prevention.1 Contributing factors include congenital defect, premature delivery (< 37 weeks), low birth weight, sudden infant death (SIDS), pregnancy complications, and preventable injuries, such as suffocation. However, new research suggests that the high U.S. infant mortality rates are almost entirely due to socio-economic factors like low income and low literacy.2 In light of this worrisome report, states across the U.S. are undertaking initiatives to actively reduce their infant mortality rates. In 2009, Maryland’s infant mortality rates were 7.2% within the state and up to 13.5% within the city of Baltimore.3 Baltimore City’s “Sleep Safe” campaign through “B’more for Healthy Babies” is part of the city health department’s strategy to improve birth outcomes. In 2009, they developed the “Sleep Safe” video and in 2010, the mayor issued a proclamation to have hospitals show the video, provide education, and have mothers sign a sleep safe commitment. While the Mother/Baby Unit at the University of Maryland Medical Center (UMMC) had been providing both printed and video educational material for numerous years, there remained

an opportunity to improve the sleep safe program. From 2010 to 2013, there were 62 infant deaths in Baltimore; 34% of these babies were born at UMMS hospitals – 15 births (24%) at UMMC and six births (10%) at the Midtown campus. UMMC partnered with the Maryland Department of Health and Mental Hygiene (DHMH), the Baltimore City Health Department, and the Medical Center’s on-demand patient education vendor (TIGR) to meet the unique challenges of its patient population. In 2011, working with unit staff and leadership, Caryn Zolotorow, MS, RNC-OB; Crystal Jefferson, BSN, RN; Joan Treacy, MS, RNC-NIC; and Monika Bauman, MS, BSN, RN, the team developed an initial strategy to offer standardized video education through the Medical Center’s on-demand patient education system. All nurses were required to teach about sleep safe practice and show the video produced by the Health Department. Having a consistent standard

message helps to ensure every patient gets the same information about sleep safe practice with the hopes it will reduce infant mortality by creating a behavioral change. In 2013, an upgraded version of the video education system was implemented allowing for additional innovations. A “Mother/ Baby – New Moms” curriculum was developed and implemented, which grouped the mandatory videos under one title and included such recordings as “Sleep Safe – Alone, Back, Crib.” Having the required videos in a bundle allows staff to order all videos at once rather than each one separately. This saves staff time and makes it easy to know which videos are required prior to discharge. In May of 2015, several other innovations were developed using the same video education system: an automated posteducation quiz, a sleep safe commitment statement, an RN notification process for incorrect answers, and an automated quiz tracking system. Upon admission to the mother/baby unit, new parents are introduced to the on-demand video education system during their room orientation process. Clinical staff then uses the patient education dashboard on UMMC’s home intranet page, the Insider, to assign the bundled video curricula. This automatically adds the sleep safe post-education quiz to identify knowledge gaps. Quizzes completed with incorrect answers are automatically generated and sent via email to the manager and other appropriate nurses for additional follow-up education before the new parent is discharged. The post-education quiz also includes a commitment statement designed to highlight the importance of sleep safe practices. In addition, a complete record of survey results is retained for evaluation against outcomes data. The on-demand video education (TIGR) system is an essential part of the patient education strategy and philosophy at UMMC, with utilization steadily increasing each year. It offers an approach that improves literacy, provides standard content, and can be reviewed multiple times, allowing for greater retention and staff efficiency. It was an ideal technology to deliver the improved sleep safe initiative. Our mother/baby staff at UMMC is driving education plan adherence to ensure that this important education and information is reaching their patient population to positively affect patient outcomes. During their post-discharge home visit, 93% of the new mothers at UMMC reported viewing the “Sleep Safe” video. In the first three months after implementing the quiz, 94-100% of patients correctly answered the post-education quiz questions continued on page 22.

Winter 2016

Becoming a High Reliability Organization, continued from page 20. Each of these characteristics individually and collectively impacts the care we deliver to our patients. It is also vital to understand each of the four principles of safe design:4 (1) standardizing processes to alleviate duplication of work, time, and energy; (2) creating independent checks (having team members review medications prior to administration or mutually review a procedural checklist during a time-out); (3) learning from defects (when an adverse event [defect] occurs, asking “what happened? why did it happen? what will we do to reduce the risk of it reoccurring?”); and (4) disseminating this information to others can greatly reduce the chances of a reoccurrence of the defect.4 It is important to remember that teams make wiser decisions when there is both diverse and independent input; health care requires a team effort and is safer when all members have their input valued.4

Is aiming for zero preventable harm realistic? All patients warrant safe care and aiming for zero harm is the first step toward achieving it. It can be reached with the collective efforts of the UMMC health care teams as we continue on our journey to becoming a high reliability organization. References 1. Institute of Medicine. (1999). To Err is Human: Building a Safer Health System. Retrieved from http://iom.nationalacademies.org/Reports/1999/To-Err-is-HumanBuilding-A-Safer-Health-System.aspx. 2. National Patient Safety Foundation. (2015). Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Retrieved from http://www. npsf.org/ 3. Frankel, A., Leonard, M., Simmonds, T., Haraden, C.,Vega ,K. (Eds.). (2009). The Essential Guide for Patient Safety Officers. Illinois, USA: Joint Commission Resources. 4. Agency for HealthCare Research and Quality. (2015). Comprehensive Unit Based Safety Program (CUSP). Retrieved from http://www.ahrq.gov/professionals/qualitypatient-safety/cusp/index.html

Mother/Baby Sleep Safe, continued from page 21. and 94% committed to sleep safe practice. Most importantly, thanks to city-wide efforts, total sleep-related infant deaths attributed to the sleep environment trended down from 27 deaths in 2009 to 13 in 2014. Data is pending for 2015. We are proud of the accomplishment we made to ensure new parents understand the importance of sleep safe best practices and the fact that sleep-related infant mortality rates are decreasing in Baltimore. These are ongoing efforts and we look forward to adding further innovations to our program in the coming months. Our goal for the future is to provide the best care and education for new parents, help to improve sleep safe

practice, and contribute to reducing the infant mortality rate for our patient population. References 1. MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. National vital statistics reports; vol 63 no 5. Hyattsville, MD: National Center for Health Statistics. 2014. 2. Regenold, S.S., Baltimore’s Infant Safe Sleep Campaign: the 2014 perspective. Presentation, PowerPoint and Baltimore City Health Department Statistics, Baltimore for Healthy Babies, September 9, 2014. 3. Cohn, M. Baltimore to promote safe sleep practices for babies, August 9, 2010, The Baltimore Sun. http://articles.baltimoresun.com/2010-08-09/ health/bs-hs-safe-sleepcampaign-20100809_1_infant-mortality-rate-number-of-sids-deaths-infant-death.

Nurses – Complete most of your RN-to-BSN, MS, or DNP degree without ever having to cross Lombard Street! Fran Valle, DNP, RN, Assistant Professor and Director, post-master’s DNP without specialty, University of Maryland School of Nursing

The University of Maryland School of Nursing (UMSON) is offering the following programs to accommodate busy professional nurses. Most classes are offered online via web-conferencing. Full-time and part-time plans of study are available. ◗◗ If you are a licensed RN who has a diploma or associate’s degree in nursing, you can expand your knowledge by enrolling in the RN-to-BSN option. ◗◗ If you already hold a BSN degree, consider one of UMSON’s two online master’s-level advanced nursing specialties – Health Services Leadership and Management (ranked #5 in the nation) and Nursing Informatics (ranked #1 in the nation). A Community-Public Health master’s specialty, for which some courses are available online, is also available.

◗◗ If you hold a master’s degree in nursing or you work in the areas of health services leadership management, nursing informatics, or community and public health – and hold a master’s degree in a relevant field such as an MBA, MPA, or MPH – UMSON offers the post-master’s DNP entry option. UMSON also offers the BSN, PhD, and DNP with a variety of APRN specialties, as well as the Clinical Nurse Leader master’s option. For more information, go to: http://www.nursing.umaryland.edu/ academics, email admissions@son.umaryland.edu, or call 410-706-0501 (option 2). UMSON is currently ranked #6 in the nation by U.S. News and World Report. Members of the faculty are among the top leaders in their fields and have extensive clinical and educational expertise.

news &views PATIENT CARE SERVICES | RESPIRATORY

A Special Recognition during Respiratory Care Week Chris Kircher, MHA, RRT-ACCS, Director, Respiratory Care Services

Each year in October, the Department of Respiratory Care Services celebrates its practice with a week-long focus on education, charitable activities, and the year’s best practice moments. This year’s Respiratory Care Week began with a very special recognition that our UMMC respiratory therapists are all very proud to have received. In a partnership with the United States Air Force (USAF), our times that when I am working in my military medical capacity, I department is now an active training site for USAF reservists wish that I could have one of the respiratory therapists from the who are preparing to apply their skills as active duty respiratory Medical Center at my side. Now I know I can have a similar level therapists. Samuel Galvagno, Jr., MD, an attending physician at of expertise as a result of this training program.” UMMC, is also a lieutenant colonel in the USAF Reserve. In his Accompanied by Jason Pasley, MD, a major in the attending role, Galvagno has grown very accustomed to the USAF, and Bonnie McKinley, MAed, CRT, master sergeant and level of support and skill provided by the UMMC respiratory respiratory therapist, both active Air Force reservists working at therapists. Based on this successful working relationship, UMMC, Galvagno presented a commemorative award to serve Galvagno approached several members of the department’s as a thank you for all of the hard work that it took to put this staff and management team with a proposal to help train Air program together. Over 50 departmental colleagues were in Force respiratory therapists. In doing so, the Department would the audience when Galvagno acknowledged and gave a special be in a position to directly enhance the front line support thanks to respiratory therapists John Rouse, RRT, Terry Goodwin, where solid clinical experience and quick thinking could make RRT, Carmen Hazera, RRT, and Kelsey Burrill, BS, RRT. lifesaving differences. In the week that This opportunity was followed, staff enjoyed immediately embraced an educational program as a natural fit for the where continuing education type of training they credit and direct interface would receive in the with product vendors was care of UMMC’s trauma facilitated. Prior to our patients, as well as our week of celebration, many department’s dedication respiratory therapists to training students from participated in a charity many local respiratory volleyball tournament where care programs. To date, funds raised were sent to three reservists have the Dana and Christopher completed rotations of Reeve Foundation in support various lengths with our of the many spinal cord Front row: Chris Kircher, MHA, RRT-ACCS; respiratory therapists in injury patients cared for USAF Major Jason Pasley, MD; USAF Lieutenant Colonel Samuel Galvagno, MD; many of our critical care here at the R Adams Cowley Carl Shanholtz, MD; and Diana Johnson, MS, PT areas. This enhanced Shock Trauma Center. Maria preparation enabled two Madden, BS, RRT-ACCS, reservists to sit for their commented, “Respiratory national respiratory care credentialing boards. The most recent Care Week is the celebration of respiratory care. Our staff really reservist will be utilizing this valuable experience as the first showed how our respiratory therapists care for our spinal cord respiratory therapist to deploy as part of a special operations injury (SCI) patients by developing teams and bonding together surgical team. In this capacity, this individual will be in a position to raise money for future SCI research. The management team to care for critically injured service men and women performing showed their appreciation with a breakfast for our staff. We also in very dangerous front line roles. Galvagno stated that “the offered over 20 lectures for our staff to attend as educational civilian-military partnership established between the United opportunities for their professional growth.” States Air Force Reserve and the UMMC respiratory therapists In the months to come, the UMMC respiratory therapists will represents an unparalleled opportunity to help keep our continue to come together to support newly hired staff, hold the 4th reservists current with state-of-the-art practices. He went on to Annual UMMC Respiratory Care Symposium, and begin preparing say that “this partnership has significantly enhanced the ability abstracts for the Respiratory Care National Congress to be held of our respiratory therapists to both stay current and to stay in November 2016. It is very important to celebrate moments like abreast of the most recent advances in the field. I have said many these, and there is a lot to be proud of here at UMMC.

22 South Greene Street Baltimore, Maryland 21201 www.umm.edu

Clinical Practice Update

COMING SOON

The National Database of Nursing Quality Indicators (NDNQI®)

UMMC RN Satisfaction Survey May 2-22, 2016 Eligible RNs: • Full or part time regardless of title • A minimum of 50% of time spent in direct patient care • Employed a minimum of three months in a unit by May 2, 2016

More details to follow in April on how to access the survey.