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As a Magnet ® organization the opportunity to recognize our professional practice is an honor as it demonstrates our continued journey and commitment to service excellence. I am pleased to share the 2013-2014 Nursing Annual Report for University Hospital, which showcases the great work and contributions made by nurses throughout our hospital.
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Nursing BiennialReport 2013-2014
As a Magnet ® organization the
opportunity to recognize our
professional practice is an honor as it
demonstrates our continued journey
and commitment to service excellence.
I am pleased to share the 2013-2014
Nursing Annual Report for University
Hospital, which showcases the great
work and contributions made by nurses
throughout our hospital.
This report features select
accomplishments that reflect the
on-going commitment to adapt to
Magnet changes as well as innovation
brought about with health care reform.
Our shared governance structure
transitioned to a new professional practice model and re-designed the various
councils to better serve the needs of nurses and support more engagement of
front line nurses. As you read through this report, you will discover evidence
of how University nurses have embraced a deeper focus on patient and family
centered care as well as utilizing innovation in practice and technology to
foster the safe delivery of care both. The infusion of evidence-base research
has become the basis to guide nursing practice at University Hospital so that
the environment patient care is delivered support quality outcomes.
It is an honor that University Hospital is consistently recognized as having the
Best Nurses in the CSRA by the National Research Corporation. Indeed our
nursing staff takes their profession, passion and commitment to care for others
seriously which is evident as they embody nursing excellence in all that they do.
It is an honor and privilege to serve such an amazing team!
Sincerely,
Lynda Watts, RN, MSM, BSN, NEA-BC Vice President of Patient Care Services and Chief Nursing Officer
Welcome
Excellence IN PRACTICE
In 2013, the UH nursing staff completed the
transition to a new professional practice model.
The previous practice model was complex,
informed by an eclectic set of theoretical system
theories and models with nursing application.
After careful deliberation, the nursing SG
representatives created the new model consistent
with our philosophy and values, as well as
our previous systems approach. Depicted in
the figure below, the Excellence in PRACTICE
model is framed by University’s commitments
of Quality, Service, Teamwork, Community,
Affordability, and Professionalism and the values
of ongoing professional development; high-
quality, patient-centered care; and collaborative
teamwork. Excellence is an umbrella concept
that encompasses high-quality care, safety, and
the interdisciplinary nature of nursing with each
of the following constructs identified:
P – Patient-Centered: The patient/family/
community needs guide the focus of our care.
We respect the individuality of our patients and
advocate for quality care sensitive to their needs.
R – Respectful Relationships: The contributions
of all members of the healthcare team are to
be recognized and respected and it is nursing’s
ethical responsibility to treat others with respect
and promote environments conducive to high
quality healthcare.
A – Accountability and Autonomy: Nurses
have the authority and responsibility to practice
in accordance with established patient care
standards. This accountability is to self, patients,
members of the healthcare team, organization,
and external agencies. Nurses at University have
the autonomy to influence patient care standards
at the unit and division level and to make
choices regarding how to provide care to meet
the individual needs of patients within the care
delivery system.
C – Caring and Healing Environment: We are
committed to creating an environment to foster
patient-centered care based on the unique
physical, psychological, spiritual, and emotional
needs of each patient.
T – Technological Advancements: We are
committed to using innovative technology to
support and promote highest quality of care.
I – Interdisciplinary Collaboration: Interdisciplinary collaboration is critical to
ensuring comprehensive care within our system
and involves respecting the skills and knowledge
of each team members to optimize outcomes.
C – Continued Professional Development: We are committed to promoting ongoing
professional development to support evidence-
based care and nursing engagement.
E – Evidence-Based Decisions: Evidence-based
practice is foundational to the care provided and
nurses are expected to incorporate the best-
available information into the creation of practice
standards and daily patient care.
Patient-Family Centered Care is fundamental to
our PRACTICE professional practice model. Our
nurses do not consider family members as “visitors”
but as integral to our patients. We want families
to find University a place to help impart ease and
comfort while their loved ones receive care. The
Jernigan Cancer Center Family Waiting Room
renovation is a shining example of our emphasis
on patient-family centered care.
Looking at the Jernigan Cancer Center Family
waiting room now, it’s difficult to imagine the
former area where families were confined to
waiting, praying, resting and communicating with
extended family and friends in a small outdated
space with no windows and only one Caring
Bridge computer station. Thanks to the support
of the Volunteer Board of University Hospital
and proceeds from the Jernigan Memorial Golf
Tournament, families are now able to gather,
support one another, and retreat in an inviting and
comfortable space.
The room is beautiful, with bright natural lighting,
and includes a kitchenette, play area for children,
private bathroom, and two computer stations with
access to Caring Bridge. It helps to make the
uphill battle that the entire family fights when a
love one is diagnosed with cancer more bearable
and is reflective of the Foundation’s mission to care
for our community and families facing a battle.
A special thank you to the Jernigan Family
for allowing proceeds from the 27th Annual
Jernigan Golf Tournament to be allocated for
this renovation, the Jernigan Golf Tournament
Sponsors, the Volunteer Board, the Hospital Board,
the Foundation Board, the Projects Department,
and to the families and staff of the Jernigan
Cancer Center for their input.
Patient & Family
Centered:
Jernigan CanCer Center Family Waiting room
University’s W.G. Watson M.D. Women’s
Center has offered Mother’s Choice
“service” for well over two decades—doing
whatever we could to honor our patients
and families “special” requests. As our
namesake, Dr. Watson, said … “Service and
Kind Words.” Every one of us deserves
to celebrate/experience events in our life
in our very own way. And a birth is one
of the most memorable times in our lives!
The Golden Hour is one example of this
patient and family focus.
The Golden Hour is that first hour after
birth which has been proven to be
critical for bonding and establishing
successful breastfeeding. In 2013,
our Women’s Center nurses fully and
formally implemented The Gold Hour
to promote skin-to-skin contact with
minimal interruption as our standard of
care. Historically, babies were whisked
away from mother moments after birth
to be measured, weighed, inspected, and
warmed. However, as long as the mother
and baby are healthy there is no reason
to move the baby to the nursery and
disrupt this first hour. We find most of our
patients will immediately want to bond
with their new baby and most will want
to breastfeed; that’s the standard and we
know it’s the best. We are still sensitive to
those mothers who may not want or be
able to do so, hence MOTHER’S CHOICE.
Breastfeeding has come “full circle” and is
now even an international quality imperative,
a Healthy People 2020 goal, and one that
The Joint Commission has also introduced
as a Core Measure. We are in the initial
stages nationally of public reporting on
lactation! Moms make choices on things
like this, things they believe are (or are not)
important to them and it’s our role in nursing
to educate and support them as much as
we safely can! If parents have requests that
are outside the “norm,” we look into options,
check the literature, find out what others
do, and strive to provide the best of care.
We look to see how we can help!
Evidence-based care is a cornerstone of
our nursing practice. And we definitely
want and need to stay the front-runners,
delivering the highest standard of care — the
very best practice! Nurses have the distinct
honor of helping people; we are patient and
family advocates by profession! Being a
Magnet hospital means you have the very
best of the best of nurses; and those nurses
are focused on delivering the highest quality
of care and compassion. What better time
to start than the Golden Hour?
MOTHER’S CHOICE — for patient/family focus
aiDet respeCtFul relationships
RespectfulRelationships
Respectful relationships are a fundamental
component of our PRACTICE model. Our
nurses strive to embed the highest standards of
customer service in our patient-centered care. In
2013, University embraced the use of the AIDET
communication model to enhance respectful and
courteous communications between all individuals
within the facility.
What is AIDET? AIDET is a mnemonic reminding us
of the components of respectful communication.
It all starts with Acknowledging another person’s
presence with a smile or a word, then Introducing
ourselves and our purpose in a respectful way. We
share the Duration of what we will be discussing or
doing, so that they understand how long it will take,
then Explain what we need to do and what will be
involved. Finally, as the interaction ends, we Thank
the person to let them know we are appreciative
that they placed themselves in our care. We also
take this opportunity to invite any further questions
or needs.
We have diligently worked to “hardwire” the
AIDET process into our nursing staff, as well as
all others at University. In early 2013, 100 percent
of staff completed training in this communication
method. We are seeing related improvements in
communications, levels of patient involvement,
clinical outcomes, and patient satisfaction. Using
AIDET has guided consistent and empathetic
communication with patients and families, helping
us to always demonstrate our concern and
appreciation.
The Emergency Department (ED) is
the first con tact many of our patients
have with University Hospital and our
ED nursing staff strives to op timize
patient experiences. In 2013, the UH
ED nurses implemented a unit-based
charter to design and implement
processes to improve the triage
process for patients.
The new process ensures that a
specially trained triage nurse greets
and assesses patients upon ar rival to
registration, determining the acuity
using a 5-point scale. This early
assessment and triage allows patients
to be more quickly directed to the
appropriate area of the ED, facilitating
timely and effective care.
The ED nurse educator, Denise Simon,
BSN, CEN became a Triage First
trainer so that she could educate ED
nursing staff on implementation of
this evidence-based set of resources.
In the future, classes will be offered
monthly, as the goal is for all nursing
staff to complete the training.
In 2014, to further benefit our ED
patients, we added ER Express,
an online program allowing pa-
tients to identify when the next ED
“appointment” is available, as well as
appointment options in our the UH
Prompt Care settings.
Streamlining the Emergency
Room Experience
As part of promoting respectful
relationships, our nursing staff recognizes
the importance of professional appearance
to instill confidence by patients and our
colleagues. In 2013, University’s leadership
considered the transition to color-coded
professional attire for staff in several
disciplines, including nursing. Nationally,
other facilities have adopted color-coded
uniforms to enhance patients’ ability to
differentiate between the roles of staff
as a means of enhancing safety and
customer service. As the literature on this
subject was largely anecdotal, our nurses
conducted a brief patient survey to identify
our patients’ needs prior to transitioning to
the new color-coded dress policy.
In August 2013, after obtaining IRB
approval, the nurse researcher surveyed
patients on eight units. Patients verbalized
some difficulty in knowing staff roles and
overwhelmingly indicated that color-coded
uniforms should help in this regards. They
were complimentary of existing efforts to
identify staff, such as name tags, consistent
self-introductions, and “white boards” but
also described reliance on their ability to
read staff members’ name-tags and recall
the introductions. Thus, the move to color-
coded professional attire was made in
September to enhance patient safety and
satisfaction. University staff nurses now
wear royal blue uniforms throughout the
organization and other staff members dress
according to their discipline’s dress code.
This move to color-coded professional
attire was adopted as an evidence-
based project by nursing with follow-up
patient surveys planned. We feel that it
is important for our patients to be able
to recognize their nurses and to dress
in a way that presents a professional
appearance consistent with our licensure.
neW uniForm poliCy
University’s nursing Shared Governance (SG)
program is designed to provide a structure for
nursing staff involvement, accountability, and
promotion of quality care, ultimately improving
patient outcomes. In 2012, the nursing staff
decided it was time to revise the existing SG
structure, in place almost ten years. The new
streamlined model was implemented in late
2012 and early 2013; it includes a more simplified
division-level council structure and a more
consistent unite-level structure.
Our SG structure moves decision-making closer to
the point-of-care, with Unit Leadership Councils
(ULC) known as “triads.” Triads are comprised
of two unit nurse representatives (one from
each shift) and the nurse manager; triads work
closely with unit staff to identify and address
opportunities for improvements related to patient
care and unit processes. Unit-level SG projects are
accomplished through unit-level committees and
work groups. Triad members also represent their
units on the division-level SG councils.
The division-level SG now consists of three
councils and a number of committees and
workgroups. The councils are Transformational
Leadership Council (TLC), Exemplary Professional
Practice Council (EPPC), and Structural
Empowerment Council (SEC).
EPPC: The EPPC oversees evidence-based nursing
practice, practice innovation, and research and
includes standing committees such as the Practice
Committee.
SEC: The SEC oversees professional engagement,
professional development, teaching and role
development, community involvement, and
nursing recognition, with relevant committees
appointed.
TLC: The TLC is responsible for the overall nursing
strategic plan and consistency of nursing care
throughout the organization.
Accountability& Autonomy
ShAREd GovERNANCE
Shared Governance Touchback Sessions
unit BaseD triaD aCComplishments
Cardiac Cath Lab
Improvements resulting in decreased
radiation expo sure for staff
Cardiovascular PACU
Evaluation and selection of new cardiac
pillow, associated with increased comfort
and zero dehiscence rate
6NS and Cv3
Pilot of “pass with care” initiative resulting
in decreased pa tient falls
7NS
Implementation of pharm tech role
to enhance patient education while
supporting nurses with decreased
medication administration time
8NS
Enhanced hourly rounding with
emphasis on identification of patients at
heightened risk for falls and to ensure that
appropriate safety measures in place
10NS
Established quarterly unit newsletter to
promote communication and collegiality
among staff
10W
Enhanced patient education
processes, ensuring resources readily
available for staff on needed topics
GYN
Testing use of new patient transfer
equipment to increase patient com-
fort moving from stretcher to bed while
promoting safe patient handling
oB
Pyxis reorganization enhancing availability
of needed products while in creasing
savings
SCN
Increasing awareness of and participation
in continuing education op portunities
Ed
Instituted Triage First improving the
registration and triage process for ED
patients
Surgical Services
Creating one combined resources for
policies, proce dures, and infection control
guidance for use by all surgical areas
Each month, unit representatives to the EPPC and SEC present their unit’s charters,
describing unit-based initiatives, goals, progress, and outcomes. Examples of recent unit
specific accomplishments include:
Lynda Watts, our CNO, is a great proponent
of nursing autonomy and recognizes that our
nurses are the best resources when it comes to
identifying nursing needs. In mid-2014, Lynda
hosted a series of “Power Hours”—brainstorming
sessions with groups of nurses representing
diverse units invited to explore what our
strengths and opportunities for improvement.
During the sessions, issues such as nursing
retention and recruitment, staffing and support
roles, nursing satisfaction, patient flow and
placement, and equipment availability were
discussed. A number of initiatives emerged from
these conversations.
For instance, in summer 2014, a number of plans
were implemented to enhance nursing retention.
At the same time, nursing and human resources
launched the “80 in 80” plan aimed to hire 80 new
nurses within 80 days. The goal was exceeded,
resulting in many new nurses joining our staff.
To optimize recruitment, we instituted Magnet
Mondays. Every Monday from 9 a.m. until 11 a.m.,
a recruiter is available in the hospital lobby
to speak with nurses interested in careers at
University.
PowerHours
7ns pilot:addition of pharmacy technician role
In December 2013, the 7NS nursing staff
participated in a project de signed to
measure and review the proportion of
their time spent in var ious direct and
indirect patient care, activities, with
an aim to consider staffing options
to increase their availability to focus
on professional nursing tasks. They
found that they spent more time in
medication administration activities than
reported by other facilities. In 2014, the
interdisciplinary team reviewed options
and elected to conduct a pilot adding
a pharmacy technician role on the
nursing unit to support their medication
administration activities. A pharmacy
technician would be able assist the
nursing staff with pulling medications
for the Pyxis, obtaining the medication
history, contact patients’ pharmacies or
providers to obtain accurate medication
reconciliations, etc. This project was
successful. Based on the evidence from
7NS, the project is being replicated on
8NS in late 2014.
Lynda Watts, RN, MSM, BSN, NEA-BCVice President of Patient Care Services and Chief Nursing Officer
In 2013, the Shared Governance representatives
reviewed, updated, and approved an ongoing
strategic plan. The Professional nursing staff
within University Hospital has a robust strategic
and operating plan consistent with that of the
organizational plan. The first component is the
strategic plan, which includes the cornerstone
elements of the mission; vision, commitments and
long term strategic goals framed around five pillars:
SERVICE, QUALITY, AFFORDABILITY, PEOPLE, AND
GROWTH. The second component is the annual
operating plan, which consists of the organizational
priorities, the teams accountable for translating the
priorities and tactics into action, and the performance
measurement criteria. Both components of the plan
are influenced each year by the data generated from
numerous sources including, but not limited to, staff’s
perceptions of the professional practice environment
survey, patient satisfaction surveys, and the work of
the Shared Governance Councils.
LoNG-TERM FoCUS:
The Strategic and Annual Operating Plan is the
basis upon which the Vice President of Patient Care
Services and the Division is evaluated. Within the
strategic framework are the University Health Care
Hospital mission, vision and commitment; definition
of Nursing, goals, philosophy and objectives.
nursing strategiC plan
people
Nursing at University will attract,
retain, and develop excellence in
professional nursing dedicated to
evidence based practice and high
quality patient-family centered care.
groWth
Nursing at University Hospital
will engage staff in activities that
promote expanding services for our
community.
aFForDaBility
Nursing at University Hospital will
be engaged and supported by a
professional practice culture and
climate which supports cost effective
care delivery. Through structural
empowerment nursing will design and
contribute to the development of the
future cost containment strategies.
Quality
Nurses at University Hospital will
place quality-caring relationships
at the center of our practice
resulting in safe compassionate care
demonstrated by excellence in patient
outcomes.
The following depicts the primary goals
under the categories of People, Growth,
Affordability, and Quality.
In March of 2013, University Hospital implemented
a safe patient handling program to prevent injuries
and ensure safety for patients and staff. The
development of our safe patient handling program
began in October 2011 with an equipment
expo to display transfer and mobility devices
by ArjoHuntleigh, Inc. Staff were encouraged
to “test drive” the equipment and submit
recommendations for purchase. Equipment was
purchased based on these recommendations in
2012. For a period over 6 months, employees
were trained on the safe mechanics of lifting
and use of the transfer and mobility equipment.
To ensure mastery of necessary skills, each
employee was required to return-demonstrate
the use of any equipment/devices purchased
for his/her unit. Practice standards and
computerized documentation have been revised
to accommodate the changes in clinical practice.
While hospitals have traditionally relied heavily
on body mechanics training, there is considerable
evidence-based research that indicates this
training alone is not effective in preventing strain/
sprain injuries associated with patient lifting.
The United States Bureau of Statistics, based
on information from the Department of Labor
Occupational Safety and Health Administration
(OSHA) indicates nurses and patient care
assistants are consistently within the top ten of all
occupations at risk for physical injuries. Two years
prior to implementation of the program, greater
than 15% of all employee injuries were the result of
patient care related strains/sprains. The incidence
of patient-care related strain/sprain injuries was
cut in half following introduction of the equipment.
Caring &Healing
Environment
SAFE PATiENT hANdLiNG PRoGRAM
Sacral Preventative dressing ForCaring and healing Environment
As an organization consistently seeking
ways to promote a caring and healing
environment, University Hospital has a long
history of extremely low pressure ulcer
prevalence. However, the nursing staff
continually seeks opportunities to further
decrease, if not eliminate, ulcer formation
all together.
In mid 2013, after performing months
of testing showing consistent positive
outcomes, the nursing staff decided to
implement the use of a new foam sacral
preventative dressing. They then continued
to be engaged with the implementation
of this new dressing by aiding in the
development of policies, in services, and
modifications to the electronic health
record as well as the development of a
nurse driven protocol to address at risk
patient populations.
Once substantial education was completed,
the use of the new sacral dressing was
implemented house-wide for those patients
who met high-risk criteria. The use of this
dressing has now aided in a measurable
decrease in the development of new sacral
pressure ulcers, as evidenced by our 2013-
2014 Quarterly Preventative Studies.
Q4 2012
Q1 2013
Q2 2013
Q3 2013
Q4 2013*
Q1 2014
Q2 2014
Q3 2014
Q4 2014
Sacral Ulcers 3 4 3 0 0 0 0 0 0
3
4
3
0 0 0 0 0 0 -0.5
0.5
1.5
2.5
3.5
4.5
5.5
Number of Sacral Ulcers Q4 2012--Q4 2014
Technological Advancements
UH has consistently evaluated emerging technology for evidence that it would favorably contribute to the outcomes of our care. In 2013, in addition to the continued implementation of EPIC, our electronic health record (EHR), a number of other resources were tested and several implemented.
The EPIC electronic health record (EHR) is a key
component in improving patient safety, clinical quality
outcomes, service, and operational performance.
University nurses have historically been instrumental
in the design and implementation of our electronic
resources and EPIC was no exception. University
implemented the EPIC EHR in December 2012 and
early 2013. Throughout the planning phases and
ongoing evaluations, clinical nursing staff members
have been included in the decision-making processes
related to enhancing our documentation system to
not only meet regulatory guidelines, but to improve
efficiency in providing patient care. Engaging
nurses in throughout the process empowers them to
improve professional nursing practice. An example is
the development of Best Practice Advisories (BPAs)
which alert the nurse to required documentation
components, such as home medication review,
immunization screening, and heart failure education.
Optimization of the EHR is an ongoing process that
will assist in keeping ahead of inevitable changes in
health care, while maintaining excellence in nursing.
EPiC: TEChNoLoGY
LUCAS 2 TEChNoLoGY
In 2013, the emergency was very fortunate to obtain
the LUCAS 2 compression system, an example of
new technology enhancing clinical outcomes. The
LUCAS 2 system is designed to deliver uninterrupted
compressions at a consistent rate and depth, in
order to facilitate return of spontaneous circulation.
As any nurse knows, performing manual CPR is
difficult and tiring. However, high quality CPR is
vital in order to deliver oxygen to organs while
maintaining sufficient coronary perfusion. LUCAS
is portable, lightweight, and easy to use. It frees
up a nurse or other staff member who would
ACCUvEiNS hAvE ARRivEd ... FoR TEChNoLoGY
The AccuVein 400 is a vein illuminator that helps
nurses and other clinicians locate superficial veins up
to 10mm. It operates using infrared light to detect
veins beneath the skin, then projecting the position of
the veins on the skin surface directly above the veins.
During July and August, 2013, a clinical evaluation of
the device was conducted by clinical nurses. Based
on overwhelmingly positive reactions from both staff
and patients, 21 devices were purchased. All relevant
nurses were educated on the use and maintenance
of the device, including vein location techniques, in
October 2013, when the devices were made available
throughout the organization.
otherwise be performing chest compressions. Most
importantly, it leads to improved patient outcomes,
our final goal.
Nursing is represented as essential part of the many UH interdisciplinary teams. Our teams have successfully pursued and maintained quality resulting in a number of national certifications and/or recognitions, including heart failure, chest pain, stroke, total joints, breast health.
hEART FAiLURE iNTERdiSCiPLiNARY TEAM:The Heart Failure Interdisciplinary Team (HFIT) is nurse led collaboration whose goal is to provide the highest quality care to the patient. An interdisciplinary team offers their professional knowledge and experience to solve problems to improve patient outcomes. The HFIT consists of Physicians, Heart Failure Program Coordinator, Nurse Managers, Staff Nurses, TeleHealth Nurses, Pharmacists, Registered Dieticians, Case Management, and Performance Improvement. Fall 2013 University Hospital’s Advanced Heart Failure program was surveyed by The Joint Commission, who identified opportunities for the organization to improve care of the heart failure patient across the continuum. As Heart Failure Program Coordinator and Leader of the HFIT, Terri DeFusco, BSN, RN has spearheaded the following initiatives to achieve success with TJC identified opportunities for improvement:
n An easy self-assessment tool that would help any care giver to understand the patient’s perception of heart failure wellness. The stoplight tool provides a visual for signs of worsening HF and reminds patients to call their doctor for assistance rather than going to the emergency room. The stoplight tool is written at a fourth grade level to reach our demographic. Laminated copies of the stoplight tool are hanging in the patients rooms throughout the hospital as a visual reminder for the staff, patient and family.
n The New York Heart Association (NYHA) classification of functional capacity was chosen as the method to monitor patient’s progress throughout the continuum of care by our team. This scale was added to our EPIC admission navigator and care plan for the nursing staff
and physicians to assess the patient’s functional capacity. The change in functional capacity over time is visible to all care providers.
n Partner with the patient, to understand what goals they want to achieve considering their current condition. Focusing on the goals of the patient help us to identify their barriers and facilitate a partnership to make a difference in the transition of care to home or community. The goals and interventions are added to the care plan and discharge instructions which help the patient achieve their goals.
n Dr. A. Bleakley Chandler states “I have enjoyed our heart failure rounds over the last six months [starting in Oct. 2013]. I think it has improved the care of our patients. First, the nurses caring for these patients have gotten really good at understanding them from a heart failure point of view. They have learned the difference between systolic and diastolic heart failure and the appropriate medications. They have learned the importance of tracking their [the patient’s] weight as well as their functional class and short term and long term goals. We have also focused on advance directives. In addition, our team including Terri DeFusco and Jeff Langford, PhrmD., frequently pick up on patients who are not on appropriate medications, need to have a discussion about an AICD or who need a Cardiology consult. All in all our heart failure patients have directly benefited from our rounds.”
Through the direction of a nurse led interdisciplinary team by Terri DeFusco, BSN, RN the opportunities identified by TJC to strengthen the effectiveness of University Hospital’s Advanced Heart Failure Program have been implemented. Using feedback from frontline nursing staff and the intellectual capital of the team, the initiatives have made a tremendous difference in the ability of all disciplines to assess and clearly understand the patient’s perception of self and personal goals that result in improved
InterdisciplinaryCollaboration
The TAVR (transcatheter aortic valve replacement)
program is another example of a highly visible,
nurse-coordinated program. The TAVR program
was envisioned by Drs. Les Walters/Kraig Wangsnes
and Timothy Hunter during a conference in June
2011. This new technology that was previously only
available in Europe was soon to be available to
commercial sites in the United States pending the
outcome of the Partner Trial.
They discussed having a TAVR program at University
Hospital with the Administration. The Administration/
Board approved the possibility of having a TAVR
program. University Hospital first had to apply
to be considered a possible TAVR site and had to
meet very strict requirements set forth by the Food
and Drug Administration (FDA) and the Center
for Medicare Services (CMS) as well as with the
Edwards Lifesciences Company (the only TAVR
valve company at that time). Once the requirements
for both the facility and the physicians were provided,
University received approval to start their program.
(Summer/June 2012).
They had to hire a coordinator for the program and
establish a formal clinic to screen potential patients
diagnosed with severe aortic stenosis as defined by
the American Cardiology College organization (ACC)
Severe Aortic Stenosis is defined as: A Jet velocity
> 4.0; Mean Gradient > 40 mmHg; Valve Area < 1.0
cm2/m2 or a valve index < 0.6. In addition, to be
eligible for the TAVR procedure, the patients had to
be seen by 2 cardiothoracic surgeons and deemed
inoperable (not candidates for traditional open
surgical aortic valve replacement or SAVR).
By Sept 1, 2012 a coordinator was recruited (Susan
Wodarz, RN, BSN) and patients identified with severe
aortic stenosis were seen in a clinic space on the
Cardiovascular Care Center (CVCC) one Tuesday
per month. An Average of 5 patients seen per month
were seen within the first few months. In November
of 2012 the indication for patients considered High
Risk was approved by the FDA and CMS which
increased the new referral numbers to 10 plus
patients per Tuesday.
By December 2012, the need for additional clinic days
and more clinic space was evident. The Structural
Heart Clinic was formed and began seeing patients
in a shared area with the Weight Management Clinic
located on the first floor of the Heart and Vascular
Institute in January 2013. (Clinic days are now every
other Tuesday throughout the month.)
On February 5, 2013 the first TAVR procedure was
successfully performed in the hybrid OR.
By the end of December 2013 we had screened close
to 100 patients identified with Severe Aortic Stenosis;
completed 25 successful TAVR cases; referred 12
patients for traditional SAVR and continued to follow
patients who are in need of TAVR but have not quite
met the criteria.
To date, our hospital has completed a total of 31
TAVR cases. We have a 100% procedural success
rate (which means that 100% of our patients have a
successful implantation of their new valve and leave
the OR alive) A statistic that is shared by only a few
hospitals in our Region.
The TAVR program (Structural Heart Clinic) continues
to grow and flourish under the Collaborative Heart
Team made up of one RN and 8 Physicians (2
Interventional Cardiologists; 2 CT Surgeons;1 invasive
cardiologist; 1 cardiac anesthesiologist; 1 Radiologist)
and many supportive departments throughout the
hospital (CVCC; CVP diagnostics; Radiology/CT; Pre-
op testing; Surgery Care Center; Cath. lab staff; OR
staff; CVPACU staff; CV3 Staff)
The high quality outcomes of the TAVR patients are
due to the entire team of health care professionals
(Physicians, Nurses, and Techs.) at University Hospital
doing what they all do best!
taVr program:
Annually, our nursing staff recognizes those
among them who have taken the added step to
demonstrate excellence through achieving national
certification. In 2013 and 2014, we recognized
significant gains in the number of nurses with this
distinction — an increase of approximately
59 percent between 2012 and 2014.
Our efforts to promote certification amongst
our nursing staff include hosting certification
prep courses, peer-to-peer encouragement,
examination fee reimbursement, and an hourly
differential for certified nurses. In late 2013,
our certified nurses got a new resource to help
them maintain their credentials when University
subscribed to the EBSCO Nursing Reference
Center. Suddenly our nurses gained access to
hundreds of evidence-based continuing education
programs, in addition to the many other resources
incorporated in this resource. We anticipate that
having this resource available to our staff at point-
of-care and from their personal computers will
enhance their ability to earn the necessary CE to
support their maintenance of certification.
CERTiFiCATioN
Continuing Professional
Development
In December 2010, the landmark IOM Future
of Nursing report was released. One of the
recommendations made was to increase the
proportion of nurses at the baccalaureate or
higher level to 80 percent by the year 2020.
At University, we have made a commitment to
pursue the 80 percent by 2020 goal, focusing
on our staff nurses. A number of resources are
in place to support academic advancement by
our nurses, including tuition reimbursement,
scholarships, and organization partnerships with
academic nursing programs. In 2014, during a
major hiring initiative, we instituted a requirement
that newly hired non-BSN prepared nurses
commit to obtaining the degree within 4 years.
This move will enhance the success we have
already achieved. Between 2011 and mid-2014,
we increased the percentage of staff nurses with
baccalaureates from 50.1 to 58.4 percent -- an
increase of almost 17 percent in three years!
AcademicContinuing
ProfessionalDevelopment
Nursing retention is a major issue for
hospitals and providing an effective
transition from the academic setting
to the hospital setting is filled by both
excitement and apprehension for the
graduate nurse. In 2014, the ED
director sought opportunities to improve
the transition of graduate nurses into
the ED. The ED clinical educator,
Denise Simon, BSN, CEN developed
a 13-week Emergency Department
Fellowship Program for graduate nurses,
incorporating the Emergency Nurses
Association (ENA) online orientation
course which covers a broad scope of
practice to deliver quality urgent and
complex care for patients across the
lifespan as part of an orientation plan.
The Fellowship, launched April 2014,
consists of orientation time, clinical
lectures and the ENA course. In 2014, 17
graduate nurses successfully completed
the Fellowship, which was offered three
times.
Ed FELLoWShiP LAUNChEd
Evidence-based decision-making is employed
throughout our facility and the nursing staff. UH
has a number of resources in-place to support this,
including online resources readily-available, such
as the EBSCO nursing reference center and the
cadre of clinical nurse educators.
CvPACU BLood FiLTER—EvidENCE BASEd CARE
CVPACU staff nurses Sandee Daust and Robin Slagle
asked the question: Why do we double filter blood
when administering packed red blood cells (RBCs)?
While we had done this for at least 25 years, no one,
including our cardiothoracic surgeons, remembered
why it was originally ordered in that way. Sandee
and Robin implemented an evidence-based practice
project to examine the available evidence and
literature to determine whether double-filtering of
packed RBCs was necessary in open heart surgery
patients and considered a cost analysis of the Pall
filters used in CVPACU.
Finding no literature to support the practice of
double-filtering the blood, they took the question
to University’s Microbiology and Lab Manager,
who assured them that all blood administered at
University is leukocyte washed, negating the need
for double filtering. Further, it was determined that
there would be significant savings in eliminating the
un-necessary practice. The annualized cost savings
from eliminating the extra filter was $3,500 and there
would be further savings in nursing time. Thus, it was
a win-win for all when a new practice standard was
approved in 2013, eliminating this needless step.
This one project depicts the role of University Nurses
in promoting evidence-based practice and properly
using technological advancements, components of
our nursing practice model. The reliance on evidence
and cost-savings to the organization support the
Nursing and Organization strategic plans.
EARLY ELECTivE dELivERiES
Early elective deliveries (between 37 and 39
completed weeks of gestation) have increased
dramatically in the years 1990-2006 and the US
labor induction rate more than doubled during this
period, from 9.5 to 22.5 percent, while the cesarean
rate grew to a high of 32 percent. The increase is
rates is likely due to a number of factors, including:
incorrect patient belief that it is safe to deliver as
early as 36 weeks, culture in hospitals, and fee for
service payment models. A recent review of the
literature identified the negative consequences
possible for mother and babies. Women and babies
where the mother is induced at the 37th-38th week
have significantly higher risk of having cesarean
section, postpartum complications, neonatal
mortality and morbidity, and baby’s placement in
the NICU. Both maternal and neonatal lengths of
stay also increase with either elective induction or
elective cesarean section.
An interdisciplinary committee involving physicians,
clinical educators, clinical nurse director, nurse
managers, and later unit clerks, assistant nurse
managers and nursing staff. They set a goal in L&D to
decrease EEDs to zero, or less than 5 percent which is
one of the core measures as a shift in culture towards
evidence-based care.
The committee established an algorithm of when and
how to receive inductions in the OR as well as L&D for
the unit clerks. A Hard Stop was initiated September
25, 2013. We have a significant decrease. The rate
had decreased to 6.3 percent in December 2013 and
3.1 percent in December 2014.
Evidence Based
Decisions
1350 Walton WayAugusta, GA 30901
www.universityhealth.org
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