Transitioning Registered Nurses

Utilizing the

Resource Nurse/Partners in Practice Model

FOR Med/Surg

Contingency Planning for Surge Capacity during

a Disaster Event

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Updated: 6/25/2020

Resilience

At HCA Healthcare, we’re no strangers to threats. We deal with them daily.

Infectious diseases, natural disasters, unspeakable emergencies.

Some say that managing life-threatening situations is part of business as usual for an advanced

healthcare network like HCA Healthcare. And it’s true.

That’s exactly what helped build a sharp set of best practices and a robust network of response

teams, which helped us, HCA Healthcare, mobilize quickly and scale accordingly in times of

need.

As this latest threat evolves, HCA Healthcare is collaborating with federal and local health

agencies, providing timely and practical updates that will help contribute to accurate reporting

and consistent guidelines. While our immediate priority remains the well-being of our patients

and people, we know that sharing insights can impact care far beyond the communities we

serve.

In the face of a threat, we don’t panic, we prepare.

Introduction

Our everyday lives and the way HCA Healthcare provides care is drastically changing due to the

spread of COVID-19. We are faced with an unprecedented health crisis. The worldwide scale is

daunting, and the challenge to our infrastructure, standard processes of care, and even

standards of care demands novel approaches. It is during these times that our colleagues have

shown their resilience and lead us through these difficult periods.

Our goal is to support our nursing colleagues as we prepare for potential patient surges,

predominately in our Critical Care Services. To support these critical areas, we will need to

reassign registered nurses to various nursing departments throughout the market to serve in a

partners-in-practice model.

To prepare for this surge in patients, HCA Healthcare Center for Clinical Advancement teams

have come together to provide information and education for you to serve in a primary nurse

role and support various nursing units that are facing challenges related to resource gaps in

patient care.

This booklet is not all inclusive, but does provide additional information to help you build on

your current nursing knowledge and skills.

Let’s begin our journey.

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Knowledge and Skills

We recognize that each Registered Nurse (RN) brings knowledge, experience and skills to the

clinical unit that you are assigned and you may already be very comfortable with some of the

knowledge and skills listed below. Review the list below and initial those skills that you can

perform independently.

Medical-Surgical/Progressive Care Knowledge and Skills

Skills Initials Skills Initials

Vital Signs/Vital Signs Monitoring

Equipment

Central Line Management/Dressing

Change

Telemetry Lead Placement Line Draw Blood Sampling

Assessment (General/Focused/

I&O)*

ADLs/CHG Bathing

Documentation

(Meditech/Downtime)

Fall Prevention & Gait Belt Use

Medication Administration

(General) *

Nasogastric Tube Maintenance

Medication Administration (High-

Risk) *

IV Pump Utilization

Oxygen Therapy PPE Utilization

Respiratory Therapies (Nebs, MDI,

IS, MDU, EZPAP, CPAP/BiPAP)

Suction Set-Up

Pain Assessment/Management Restraints *

PCA Management * Indwelling Urinary Catheter

Maintenance

Diabetes

Management/Glucometer

CIWA/COWS Management

PIV Insertion

*To be performed the first time with Preceptor or Charge RNs oversight.

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Preparatory Learning

First, we want to introduce you a variety of e-learning modules in HealthStream to help you

better understand some of the terminology, equipment, and various medical and nursing

interventions you may encounter. In order to access the majority of the content for your

preparatory learning, you will need to login to HealthStream. To login to HealthStream from

home: www.stdavids-institute.com or healthstream.com/hca Use your 3-4 ID and

Network password. If you have never logged in to HealthStream, please follow the directions on

the login page.

You must obtain authorization from your manager prior to doing HealthStream work at home.

You should be provided time during your workday to work on some HealthStream activities.

HealthStream Modules

o Head-To-Toe Assessment-EBSCO o Med Surg Quick Reference Tools-SDH o Basic Respiratory Care Nursing Skills-EBSCO o Incentive Spirometry Education at the Bedside-EBSCO o Urinary Catheter Care-EBSCO o Restraints Overview o Limb Restraints in Adults-EBSCO o Nasogastric Tube Care-EBSCO o Fall Prevention-EBSCO o CIWA Overview o Peripheral IV Insertion o Medication Management Basics o Inpatient Glycemic Control-SDH o Welch Allyn Spot Monitor Clinical Training Video

Orientation

Introductions are crucial to team success. Each individual brings with them certain

competencies and skills. In the introduction, each member should discuss what skills they can

assist with throughout the shift. Lead or Primary nurses should discuss the care needs for

patients within the unit with their Partner in Practice and how the work can be divided up to

ensure each patient receives the best care utilizing everyone’s talents on the team. During the

orientation phase, the lead or Primary nurse will review environment of care, which will include

the safety features of the unit.

Orientation time may be limited, but as time allows we will provide hands-on-learning for

common skills, documentation, and work routines. If we are not able to provide any hands on

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training, there are huddle cards and videos that you will be able to access on your I-Mobile,

hospital Intranet site, or these may also be on the nursing unit for you to review.

When you arrive on your assigned nursing unit, you will be introduced to the team and

provided with an introduction to the nursing unit. This will include a document (shown on the

following page) that will provide you with items your preceptor or educator should orient you

to.

Below, you will see the Huddle Card for the Partner in Practice/Resource Nurse Model. Please

familiarize yourself with this information.

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This document below is what you should expect regarding conversations with the primary

nurses you will be supporting at the end of your shift.

Meditech Education

The clinical education team has developed training on how to utilize and document in Meditech

for the following scenarios:

Nurses in their current role who have not utilized Meditech

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Nurses who utilize Meditech in their current role and will need to document in another

care area, i.e., Med-Surg Nurse documenting in ICU or OR Nurse documenting in the ED.

Listed below are the Meditech courses, with a short description, that are located in

HealthStream:

HWS HCA WBT Meditech Nursing Documentation – this is the full course for teaching

nurses to document in Meditech utilizing Evidence Based Clinical Documentation.

COVID-19 Medical-Surgical Meditech Resource Toolkit – this course will provide a

nurse who has basic experience with Meditech, how to document in adult inpatient

units, such as Med-Surg, Telemetry, and Critical Care. There is a word document with

screenshot examples that can be printed.

HCA Healthcare Center for Clinical Advancement is excited to announce the launch of

a Meditech Assistance Hotline starting Friday, 4/3/20. This will be for staff and any

clinician who needs assistance with Meditech. This will be extremely useful for those

nurses who are moving to other nursing units.

Meditech Assistance Hotline

For Meditech assistance please call us at 1-800-737-8661 x1333 or 954-514-1333 and

select option 2 to contact an experienced Meditech instructor.

Hours:

Weekdays: 8AM – 5PM EST

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Just In Time Resources

In the Primary Nurse Practice model you are not going to have all the knowledge and skills as

you deploy to another practice area. That is ok! As a Registered Nurse, you understand you

need to ask questions. We want you to use your resources that you have available. We have

developed resources that include information and guidance to help provide excellent care. If

you cannot locate a resource please ask your educator, we are here to help you!

ONLINE RESOURCES AND REFERENCES:

Resource Name Description Location

Atlas HCA corporate intranet-HCA initiatives

and documents SDH intranet>Atlas Connect

CE Direct Free access to continuing education and

certification review courses SDH intranet>Clinical Tools; internet

access available

Clinical Pharmacology Drug reference, including medication interactions, compatibility, etc.

SDH intranet>Medical Resources

EBSCO Clinical Research Clinical research database-to access

specific articles or journals

SDH intranet>Medical Resources; internet access available

E-Demand Repository for facility/SDH forms

(consents, specific patient instructions, etc.)

SDH intranet>Admin Tools

HealthStream

SDH/HCA Learning Management System- repository for most mandatory and

elective learning; HealthStream Competency Center: electronic orientation and annual

competency assessment for all staff, as well as annual evaluations;

HealthStream CE Center: free access to continuing education and certification

review courses

SDH intranet>Admin Tools; internet access available

Dynamic Health SDH procedure manual, includes

instructions, checklists and references SDH intranet>Medical Resources

Policytech Electronic file for SDH policies SDH intranet>Policies

Institute for Learning (IFL) Course Registration-for any course

offered through the IFL

SDH intranet>Institute for Learning; internet access available www.stdavids-

institute.com

COVID Resources HCA Corporate education tools

available to support COVID education

SDH intranet>Atlas Home>HCA Center for Clinical Advancement>Education

Tools https://connect.medcity.net/web/cca/e

duresources

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HUDDLE CARDS/QR Codes – You are likely to see huddle cards or posters throughout

the nursing unit and on some equipment. For additional information about a specific

topic or to better understand equipment, please scan the QR code on the document.

Many of these documents will include videos.

VIRTUAL PRECEPTOR – we are introducing our Virtual Preceptor that is available

through I-Mobile. This will include numerous quick references on a number of topics.

These tools are designed for rapid review immediately prior to performing a task.

APPENDIX

The appendix will provide you additional information that you will find helpful. Listed below

are the various topics that you can find located in this section:

Reassigning nurses to other nursing units using the Donna Wright Model

Monitoring Patient Vital Signs

Common Medications given in Med/Surg

Reassignment of Nurses – Based on Donna Wright Model

When nurses are floated from one nursing unit to another the issue of competency arises. We

need to frankly ask does this nurse have the skills, knowledge, and abilities to function in this

capacity? Experiencing a surge of patients can make it difficult to cross-train or put nurses

through a complete orientation. If this occurs, how can we facilitate a successful floating

process? According to Donna Wright, when asking nurses who float and those who receive float

nurses, there are three themes that are consistently heard. These themes, which are actually

competencies for the nurses that are reassigned to another care area, include:

Learning on the Fly

Marketing yourself in a positive way

Understanding crisis management options

Learning on the Fly

The learning on the fly competency has two parts to it. First I need to know what I do not

know, and be able to speak up about it. The second essential aspect of learning on the fly

includes:

I am not sure about this procedure….I am going to look it up.

I am going to ask someone how to do this.

I will use the resources that are available to guide my actions.

Obviously, this is not going to work for every procedure and task that we do, but many times

the learning on the fly skill is used successfully. To demonstrate learning on the fly, a nurse is

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floated to a medical-surgical floor that does dialysis. The nurse has never worked in dialysis

before and does not know how to do dialysis. The charge nurse may ask an experienced nurse

to set up the dialysis and identify the basic things to assess when monitoring a patient on

dialysis. The charge nurse can pair the inexperienced nurse with a seasoned nurse to answer

further questions to support the patient’s care. The most important thing is to propose ways

you can be useful while remaining open to learning new things.

Marketing Yourself in a Positive Way

As a Registered Nurse you have lot of knowledge, skill and experience that you can bring to any

situation. As RNs, we need to market ourselves and let those you are working with understand

what skills and experience you can bring to the team. Sometimes we may want to say I was told

to come here, I have never worked here before, I am not familiar or comfortable with working

in this area or specialty, and I do not know how to do any of those things. However, when you

are reassigned to another nursing unit we recommend that you make these two statements to

the team or the charge nurse instead:

My name is ________ I am floating to your unit for this shift, I am here to help you.

I have the following skills that I can offer to you today, and you can determine how they

best fit your needs. I can do ___________, and so on.

When nurses have the ability to market themselves positively, the results and the shift are

much better. The success of the shift and the reassignment experience do not lie in the clinical

skills, but instead in the can do attitude the person brings.

Understanding Crisis Management Options

Most of the time when a nurse is reassigned to another area, that area is under stress,

stretched, or moving into crisis mode because they do not have enough staff to meet the

needs. They need help to function, so they reach out for support. The nurse being reassigned

can provide care and/or service assistance to help the team get the routine work done, but can

also offer something else: a fresh perspective or insight that the group may have trouble

seeing. Here is an example:

The skill of understanding crisis management options can work in any area, not just in nursing.

The team is able to change the normal workflow temporarily to match the crisis situation and

still produce the desired results.

This is an excerpt from Donna Wrights, Competency Assessment Field Guide for Implementation

and Application, 2015, Creative Healthcare Management. Prior to COVID-19, HCA Healthcare

began to transition to the Donna Wright Competency Assessment Model. We will resume the

implementation later in 2020.

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Monitoring Patient Vital Signs in the Medical/Surgical Setting

Normal Vital Signs

Temperature:

97.6-99.9F (36.4-37.7C)

Respiratory Rate:

12-20 Breaths per minute

Heart Rate:

60-100 BPM

Blood Pressure:

Systolic (top number)

o Normal=90-140

o Abnormal is anything greater than 140 or less than 90

Diastolic (bottom number)

o Normal 60-90

o Abnormal is anything greater than 90 or less than 60

Oxygen Saturation:

Report any value of 89% or less to the Physician

Report any significant drop in saturation

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Common Medications in Med-Surg Cardiovascular Class/Indication Tips

Furosemide (Lasix) Diuretic/Removes excess fluid

Monitor electrolytes Don’t give later in the eve, if they do

not have an indwelling catheter in place

Lisinopril (Prinivil, Zestril)

Lotensin

Captopril

Enalapril (Vasotec)

Quinapril (Accupril) Clonidine (Catapres) (po or

transdermal)

Ace Inhibitor/ Decreases BP

Anti- hypertensive/ Decreases BP

Avoid in patients with renal compromise

Monitor BP

Angioedema (side effect)

Diltiazem (Cardizem)

Amlodipine

Nicardipine Nifedipine (Adalat,

Procardia)

Captopril

Calcium Channel Blocker/ decreases BP

Anti-hypertensive decreases BP

Anti-arrhythmia/ used in atrial fibrillation

Monitor BP

Some are long acting preparations to be given only once per day (CR, XR, XL)

Atorvastatin (Lipitor) Simvastatin

Lovastatin

Rasuvastatin

Pravastatin

Statin/Decreases cholesterol/LDL/HDL

Monitor Liver Function

Clopidogrel (Plavix)

Tigagrelor (Brilinta)

Prasugrel (Effient)

Dipyridamole Dipridamole/aspirin

(Aggrenox)

Ticlopidin (Ticlid)

Anti –Platelets/Blood Thinner

Monitor for any signs of bleeding

Labetalol (Normadyne, Trandate

Metoprolol (Lopressor, Toprol XL)

Atenolol (Tenormin)

Carvedilol (Coreg)

Nadolol (Corgard)

Beta- Blockers/ decreases BP and heart rate

Monitor BP

Monitor Heart rate

Warfarin (Coumadin) Blood Thinner Monitor INR lab values

Typically given in the evening Monitor for signs of bleeding

(Blood in urine, excessive bruising)

Avoid foods high in Vitamin K

Reversal agents: Vitamin K and FFP

Clonidine (Catapres) (po or transdermal)

Anti-hypertensive Can be oral or transdermal preparations

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Common High-Risk Medications Given on the Med-Surg Unit (Heparin, Insulin, TPN, PCA)

Medication Name

Indication/Drug Classification

Route of Administration Nursing Tips

Heparin Anticoagulant (Blood Thinner) DVT Prophylaxis

Sub-cutaneous Sub-Cutaneous: Give in the Abdomen 1. Pinch a 2 inch fold of abdominal

skin 2. Cleanse with alcohol swap 3. Let dry 4. Inject slowly into skin fold 5. Release skin and monitor for

bleeding (may need a band aid if oozing at the site)

6. Avoid area near the umbilicus or areas of previous injection sites

Heparin Anticoagulant (Blood Thinner) TX of PE, DVT, or CV disease

Continuous IV infusion Review orders carefully: Various orders sets available based on reason for use: Low Intensity Protocol High Intensity Protocol Acute MI Non MI

1. Baseline labs prior to starting infusion (per facility)

2. Monitor lab results q 6 hours (see orders) to make adjustments to infusion rate per order set

3. Follow order set per facility: typically need 2 lab values WNL before proceeding to daily lab testing

4. Per facility requires a co-signature in Meditech

5. Document Lab phone results in Process Interventions: Manage/Refer/Contact/Notify

6. Monitor patients for any signs of bleeding and notify provider as indicated. (Blood in urine, excessive bruising)

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Medication Name

Indication/Drug Classification

Route of Administration

Nursing Tips

Insulin: Long-Acting Short-Acting Rapid-Acting

Anti-Diabetic agent

Sub-cutaneous Injections site options: Abdomen, outer lateral upper arm, thigh

1. Pinch a 2 inch fold of skin 2. Cleanse with alcohol swap 3. Let dry 4. Inject slowly into skin fold 5. Release skin and monitor for bleeding

(may need a band aid if oozing at the site) Avoid areas of previous injection sites

Long-acting: Detemir (Levemir) Glargine

Follow order:

Typically given at HS, can be BID dosing.

Take blood glucose prior to administration

Do not mix with other insulins

Short-Acting Regular

Follow Sliding Scale order set: Various Sliding Scale order sets: Review

carefully: some involve basal dosing as well as scheduled dosing and various adjusting based on the Blood Glucose result

Blood glucose prior to administration

Give within 30 minutes of meal

Rapid-Acting Lispro/Aspart Has a more rapid onset and shorter duration than Regular Insulin

Follow Sliding Scale order set: Review carefully: some involve basal dosing as well as scheduled dosing and various adjusting based on the Blood Glucose result

Take Blood Glucose prior to administration

Give in close proximity of meal Do not mix with other insulins

Combination NPH/Reg Lispro/Prot Novolog 70/30

Follow orders: Take Blood Glucose prior to administration

Blood Glucose can be a lab draw or a finger stick

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Medication Name

Indication/Drug Classification

Route of Administration Nursing Tips

TPN Total Parental Nutrition

Nutrition Intravenous

MUST BE ADMINISTERED IN A CENTRAL LINE (PICC is a central line)

0.22 micron filter is required

Follow order instructions carefully: Typically has a starting dose and then increases per order and a wean if discontinued

Do not stop abruptly

Must be co -signed prior to administration

Dietician involved in dosing adjustments based on labs

Blood glucose monitoring per order

Needs a dedicated line (DO NOT administer other medications into the line)

Lipids Fat emulsion Intravenous Follow order set instructions carefully:

Typically given on certain day(s) of the week in conjunction with TPN

Per facility may have a solution with TPN and Lipids in one bag

Refer to policy regarding filtration of lipids.

Check with Primary RN

If you have any questions, please reach out to the St. David’s HealthCare Institute for Learning at 512-544-0100 or via e-mail at SDHP.DL IFL Clinical Education

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