Inside: ProTech Students Participate in NYLF ............................... 1 Jeanette Ives Erickson ............ 2 Reflecting on the important work of PCS clinicians Fielding the Issues .................. 3 Medical Team Regionalization Collaborative Governance ...... 5 Patient Education and Ethics in Clinical Practice Committees Collaborate Exemplar ................................. 6 Barbara Cashavelly, RN Clinical Nurse Specialist ......... 8 Mary Guanci, RN Quality Committee Update .. 10 10 10 10 10 Educational Offerings ........... 11 11 11 11 11 PFLC Celebrates 5th Anniversary ...................... 12 12 12 12 12 C aring C aring May 6, 2004 H E A D L I N E S Working together to shape the future MGH Patient Care Services MGH ProTech students participate in National Youth Leadership Forum (See page 4) ProTech student, Melissa Diaz (right), primes IV tubing under the watchful eye of White 11 staff nurse, Maura Hines, RN.
Transcript
Inside:ProTech Students Participate
in NYLF ............................... 11111
Jeanette Ives Erickson ............ 22222Reflecting on the important
work of PCS clinicians
Fielding the Issues .................. 33333Medical Team Regionalization
Collaborative Governance ...... 55555Patient Education and
ProTech student, Melissa Diaz (right), primesIV tubing under the watchful eye of White 11
staff nurse, Maura Hines, RN.
Page 2
May 6, 2004May 6, 2004Jeanette Ives EricksonJeanette Ives Erickson
Jeanette Ives Erickson, RN, MSsenior vice president for Patient
Care and chief nurse
Springtime: a time to reflect on theimportant work and accomplishments
of our clinicianswonder if admini-strators at otherhospitals feel asproud and fortu-
nate in their jobsas I do in mine. When
I think of all the wonder-ful outcomes and accom-plishments of cliniciansat MGH, I’m filled witha sense of pride and re-spect. I can’t imagineworking with a moretalented, committed, orcaring group of profes-sionals.
Think of how manypeople are touched byyour knowledge, skill,and compassion everyday. Think of the impactyour collective accom-plishments have made inthe past year.
Last summer, mem-bers of our Medical-Surgical Response Team(IMSuRT) and Boston’sDisaster Medical Assist-ance Team (DMAT) cametogether on the groundsof the Bedford VA Hos-pital for a three-day train-ing drill that simulated amajor medical disaster.Clinicians from PatientCare Services had anopportunity to hone theiremergency-preparednessskills in a ‘real-time’disaster situation. Theirtraining paid off when,six months later, theywere deployed to Bam,Iran, to care for survivorsof one of the worst earth-quakes in recent history.The team spent nearlytwo weeks working outof a portable field hospi-tal under extreme and
I austere conditions. Theteam’s presence in Iran,not only saved lives, itforged relationships withthe people of Iran, a coun-try that has long beenestranged from the Unit-ed States.
Also this year, in ahospital-wide undertak-ing, MGH became thefirst Magnet Hospital inMassachusetts. Muchhard work went intopreparing for the Magnetreview process, includ-ing the invaluable workof our Magnet champ-ions, 177 staff nurseswho, in a seamless andcoordinated effort, com-municated the Magnetmessage to every unitand setting in the hospi-tal. All clinicians playeda pivotal part in the Mag-net site visit, articulatingour practice philosophy,values, and commitmentto providing the safest,highest quality care toour patients.
You played a key rolein the success of ourJCAHO accreditationvisit this past September,and are vital contributorsto the development andimplementation of ourstrategic plan.
I’m thrilled to see somany MGH cliniciansbecoming involved inhumanitarian outreach,both independently andthrough MGH-sponsor-ed programs. Recent tripsto Haiti and Cuba broughtmuch-needed medicalcare, supplies, and equip-ment to some of the mostimpoverished areas of
the world. And on Fri-day, April 2, 2004, twoMGH staff nurses be-came the first nurses toreceive the Thomas S.Durant, MD, Fellowshipin Refugee Medicine.The fellowship will al-low these nurses to sharetheir knowledge and skillwith under-served pop-ulations in developingnations.
A number of inter-disciplinary programsand initiatives have beenimplemented to helpeducate patients, famil-ies, clinicians, and thegeneral public on issuesrelated to patient careand safety. The HandHygiene Initiative is onesuch program wherepractice was changed toincorporate hand-wash-ing with an alcohol-basedsolution before and afterpatient contact to mini-mize the risk of noso-comial (hospital-acquir-ed) infections.
The Patient LiteracyProgram was implement-ed to help clinicians rec-ognize, assess, and de-sign care plans to meetthe needs of patients whoare unable to read.
In the EmergencyDepartment, staff devel-oped an educational for-um called Skills Day as away to share their exper-tise with colleagues andpeers. Sharing knowledgeand experience contrib-utes to continuity of careand adds another level ofassurance to patientsafety.
A new program pairsmedical students withstaff nurses for an inter-active job-shadowingexperience. The programprovides an opportunityfor nurses and physi-cians to gain understand-ing of one another’s dis-ciplines and develops astrong basis for commu-nication and collabora-tion.
The Pet Therapy Pro-gram, a collaborativeeffort between Nursingand Volunteer Services,is an enormous successamong patients and staff.Clinicians report an in-creased level of relaxa-tion and emotional well-being in patients after petvisits. And handlers re-port that pet therapy dogshave a positive effect onjust about everyone theycome into contact with!
On a daily basis, PCSclinicians bring local,state, and national recog-nition to our hospital—with the awards youreceive; the books andarticles you write; theresearch you conduct;and the influence youexert on entities withinand outside of health
care. Interdisciplinaryteams from Patient CareServices have coordinat-ed conferences on Dis-parities in Healthcare,Disabilities, Diversity inChildbearing, and manyother important topics.Clinicians from all disci-plines participate in stu-dent outreach programsincluding Job ShadowDay, the SummerWorksProgram, the ProTechProgram, our TimiltyPartnership, and mostrecently, the NationalYouth Leadership For-um. There is a focusedeffort by all staff to im-prove care and ensurequality and safety inevery patient interaction.Programs like the Health-WISE Lecture Series, theClinical Pastoral Educa-tion Program, Pain Re-lief Champions, and somany others strive toimprove the quality oflife and the quality ofcare for our patients andthe community. Your par-ticipation in collabora-tive governance helpsmake us all better clini-cians and better caregiv-ers.
acting on feedback fromstaff nurses and housestaff, now meet on a reg-ular basis to review theway daily patient rounds
orientation guides tohelp facilitate the entryof new interns and res-idents rotating to theteam.
The Code and Emer-gency Response Com-mittee has developeda code and emergen-cy documentationform to enhance ourability to documentcardio-pulmonary-arrest events and pro-vide meaningful dataregarding the out-comes of those events.The form has under-gone an extensiveapproval process andis now ready for im-plementation.
This month, allareas of the hospitalwill receive packetsdescribing updates tothe policy and in-structions on how to
Coming Soon:New Code and Emergency
Documentation Formuse the new form. Formswill be placed on codecarts beginning June 1,2004.
Code and emergencydocumentation formswill be used in the eventof a cardio-pulmonaryarrest or other bedsideemergency requiringsuch documentation.Two copies will be keptin the white binder onthe code cart. The nursecaring for the patient willbe responsible for ensur-ing that documentation iscompleted. The medicalsenior resident, serviceresident, or physician incharge of the event willreview the form after theevent and sign it, thereby
endorsing the medica-tions and interventionsthat occurred during thecode or emergency.
The white form willbe placed in the patient’smedical record. The re-verse side of the yellowcopy will be filled out bythe clinical nursing su-pervisor and forwardedto the Office of Qualityand Safety. The Office ofQuality and Safety willcollate data from theforms and generate re-ports that will be used toanalyze outcomes.
For more informationon code and emergencydocumentation forms,call Colleen Snydeman,RN, at 724-4920.
s
Jtc
Jeanette Ives Ericksoncontinued from previous page
A new book by Bar-bara Ravage entitled,Burn Unit, captures thehealing work and hero-ism of staff on our ownBurn Unit. One testimo-nial on the book jacketreads, “A book aboutgood healers and medi-cine at its best, of selflesscrusaders, teamwork,and passionate patient-centered care, Burn Unitis unforgettable.”
At this year’s Na-tional Disaster MedicalSystems (NDMS) Con-ference, attended bymore than 2,600 DMATteam members from ac-ross the Untied States,Marie LeBlanc, RN,nurse manager for White7 and Ellison 7, receivedthe IMSuRT Volunteer ofthe Year Award; andBrenda Whelan, RN,staff nurse in the Surgi-cal Intensive Care Unit,received the Burn Team
Volunteer of the YearAward.
When I think of allthe contributions youmake, I am truly filledwith wonder. I can’t ima-gine working with a moretalented, committed, orcaring group of people.
UpdatesI’m pleased to announcethat Susan Strengrevics,RN, has accepted theposition of clinical nursespecialist for the Ellison10 Cardiac ArrhythmiaStep-Down Unit.
Donna Jenkins RN,nurse manager for Phil-lips House 22, will ex-pand her scope of lead-ership to include Ellison19.
Patti Fitzgerald, RN,has accepted the positionof clinical nurse special-ist on Bigelow 11 whereshe will job-share the rolewith Kate Barba, RN.
May 6, 2004May 6, 2004Fielding the IssuesFielding the IssuesInpatient medical team
regionalizationQuestion: What does‘regionalization’ of housestaff mean?
Jeanette: In the past,although attempts weremade to assign medicalpatients to ‘primary’units, in practice, a num-ber of house staff teamsadmitted and cared forpatients on any givenunit. A collaborativeeffort among Nursing,Medicine, Case Manage-
Emergency Departmentresulted in the March 1,2004, implementation ofa new model wherebyeach general medicalunit is covered by onededicated house staffteam. This is what wemean when we refer toregionalization of housestaff.
Question: How does thisnew model affect patientcare?
Jeanette: Having all of ateam’s patients on one‘home unit’ significantlyenhances interdiscipli-nary care planning, min-imizes delays in com-munication and inter-ventions, facilitates dis-charge preparation, andresults in an overall im-provement in patient careand satisfaction.
Question: How doesregionalization impact
among nurses, medicalteams, case managers,and other members of thehealthcare team. As teamswork together on a reg-ular basis, mutual expec-tations become clearer,opportunities to improveprocesses are more easilyidentified, and solutionsare more efficiently im-plemented.
Question:What are someexamples of improve-ments in processes?
Jeanette: Nurse mana-gers and senior residentson the medical units,
are conducted. Not onlyis it essential that teammembers participate inthe development of apatient’s plan of care, butrounds provide an in-valuable opportunity forlearning and sharinginformation.
The interdisciplinarycommunication that oc-curs during rounds re-garding a patient’s careallows more time for theeducation of house staffand students at othertimes of the day.
Managers and resi-dents are developing
Page 3
Page 4
May 6, 2004May 6, 2004
Pro-Tech studentsparticipate in National Youth
Leadership Forum
Student OutreachStudent Outreach
White 9 staff nurse, Deborah Zapolski,RN (left), explains cardiac monitor to
ProTech student, Gloria Castro.
ProTech student, Alicia DeStefano,records blood results in the Transplant
Clinic on Blake 6.
he NationalYouth LeadershipForum (NYLF)is a program de-
signed to help youngpeople make well-inform-ed choices about futurecareers by exposing themto professional workexperiences during theirjunior and senior yearsin high school. This wasthe first year the NYLFoffered a forum on Nurs-ing, and MGH HumanResources sponsored theparticipation of four MGHProTech students: Meli-ssa Diaz, Carla Casalet-to, Gloria Castro, andAlicia DeStefano.
T All four students hadsome degree of interestin healthcare careersprior to participating inthe program, but theirexperience being mentor-ed by nurses in a varietyof settings solidifiedtheir intention to choosenursing as a future pro-fession.
Says Diaz, “It was anexperience I’ll neverforget. I learned about allthe different areas andsettings where nursespractice; I saw all thedifferent things they do;I saw how different lifecan be for a seventeen-year-old girl with HIV. I
met other studentsfrom all over thecountry. If possible,my interest in goingto nursing schoolgrew even strongerbecause of this pro-gram.”
Says Castro, “Inever realized howmuch nurses know! Ihave so much respect forthem now.”
Casaletto agrees. “Ithink they should openthe National Youth Lead-ership Forum to youngerstudents, too. By senioryear, a lot of studentsalready know what theywant to do. Having anopportunity to learnabout nursing sooner
ProTech student, Carla Casaletto (left),reviews patient file with Linda Santos,
RN, in the Avon Breast Center.
could influence a lot ofkids.”
DeStefano wasn’tentirely sure she wantedto be a nurse before par-ticipating in the program.After completing theprogram, not only wasshe convinced she want-ed to be a nurse, she hadchosen a specialty! She’sconsidering gerontologyor practicing in a nursing
home. Says DeStefano,“Learning about the NProle and research oppor-tunities was very appeal-ing. I like the idea thatnurses are patient advo-cates.”
For more informationabout the ProTech Pro-gram or the NationalYouth Leadership For-um, contact Galia KaganWise at 4-8326.
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May 6, 2004May 6, 2004
Advance directives: a priorityfor Ethics in Clinical Practice and
Patient Education committees—by Gayle Peterson, RN, staff nurse, Phillips 21, and member of the Ethics in Clinical
Practice Committee and Advance Directives Task Force
ver the past sev-eral years, theEthics in Clin-
ical Practice andPatient Education
committees have joinedforces to ad-dress the edu-cation of pa-tients, clini-cians, employ-ees, and visitorson the impor-tance of ad-vance direc-tives. Discus-sions at month-ly meetings ofthe Ethics inClinical Prac-tice Committee(EICPC), incollaboration with thePatient Education Com-mittee (PEC), culminat-ed in a number of acti-vities geared at inform-ing people about theneed for advance direc-tives. Some of the acti-vities coordinated by thecommittees have beenfeatured in previous is-sues of Caring Head-lines, including threeannual Advance Direc-tives Booths in the WhiteLobby; an educationalskit for professional staffentitled, “Advance Dir-ectives: True Life Stor-ies;” a program for com-munity elders offered aspart of the Senior Health-wise Program; and fea-ture stories in the FruitStreet Physician empha-
sizing the importance ofeducation and counsel-ing on advance direc-tives.
These activities fuel-ed the enthusiasm of the
EICPC and the PEC andled to the formation ofthe Advance DirectivesTask Force. This multi-disciplinary group led bySharon Brackett, RN, co-
chair of the EICPC, setout to identify existingobstacles to patient- andfamily-education aboutadvance directives. Thegroup examined empiri-cal literature, hospitalquality-improvementdata, and anecdotal clin-ical experiences in prep-aration for fielding ateam of experts thatwould be able to educatepatients, families, andcolleagues about ad-vance directives. A pro-posal to develop a pro-gram to help educateclinicians was submittedto Trish Gibbons, RN,associate chief nurse forThe Center for Clinical& Professional Develop-ment, and Jeanette IvesErickson, RN, seniorvice president for PatientCare, who supported thisstaff-development ini-tiative.
O
Collaborative GovernanceCollaborative GovernanceTwo members of the
Advance Directives TaskForce are attending anational Advance CarePlanning Program inLaCrosse, Wisconsin,with an eye toward bring-ing the program to MGHlater this year. In No-vember, the AdvanceDirectives Task Force, incollaboration with TheCenter for Clinical &Professional Develop-ment, will host an Ad-vance Care PlanningProgram to prepare 35interdisciplinary pro-fessionals to be expertsin advance directives.Alexandra Cist, MD,physician and committeeliaison to the medicalcommunity, will assist inrecruiting physicians toparticipate in the pro-gram and become cham-pions of advance direc-tives at MGH.
The Ethicsin ClinicalPractice andPatient Educa-tion commit-tees are veryexcited aboutthis collabora-tive initiativeand the bene-fits it will bringto MGH pa-tients and fa-milies. Formore informa-tion, contactSharon Brack-ett (at 4-5100),Ellen Robinson(at 4-1765),Gayle Peterson(at 4-6110), orTheresa Can-tanno-Evans(at 4-0997).
Above (l-r): Judy Pagliarulo, RN; Barbara Kenney,RN; and Theresa Cantanno Evans, RN, and
(below): Gayle Peterson, RN; Regina Holdstock,RPh; and Sharon Brackett, RN, staff advance
directive booth in the Main Corridor.
Page 6
May 6, 2004May 6, 2004ExemplarExemplar
continued on next page
n 1998, the Pro-fessional Devel-opment Commit-
tee asked clini-cians throughout
Patient Care Services towrite clinical narrativesto assist them in theirefforts to develop a clin-ical recognition program.Barbara Cashavelly, RN,co-chair of the commit-tee, wrote a narrativechronicling her care ofAmanda Edwards, a 21-year-old college studentwho had been diagnosedwith leukemia. The nar-rative was a wonderfulexample of expert prac-tice and would certainlyhave found its way intoCaring Headlines. Butbecause Amanda’s mo-ther, Stephanie, was anMGH employee, Cash-avelly requested that itnot be published out ofrespect for her.
In 1999, Cashavellyagreed to let her narra-tive be used in a newbook, Clinical PracticeDevelopment: UsingNovice to Expert Theory,as an example of expertnursing practice. At thetime, she thought it washighly unlikely that Am-anda’s mom would eversee it. Because the bookalso referenced the workof the Professional De-velopment Committee,Jeanette Ives Erickson,RN, senior vice presidentfor Patient Care, gavecopies of the book toeach member of the Pro-
fessional DevelopmentCommittee. Through aseries of meetings andinteractions, one copy ofthe book passed hands anumber of times andended up on the desk ofPhyllis Meisel, directorof Reading Disabilities.One day, Stephanie, theoffice manager for Read-ing Disabilities, was inMeisel’s office and notic-ed the book. She pickedit up and started flippingpages when it fell opento the page containingCashavelly’s narrative.As Stephanie read, sherealized that the narra-tive was telling the storyof her own daughter. Shewas moved to tears asshe read about Casha-velly’s care ofAmanda.
Says Ste-phanie, “I wasshocked whenI happenedupon the bookand narrative.I had a viscer-al reaction,reading thisstory aboutmy belovedAmanda. Imade a copyof the articleto read at mydesk, but I hadto put it awayand take ithome where Icould read itin the privacyof my ownroom. I read
and re-read the storymany times. I knew Iwanted to share my feel-ings with Barbara.
“I contacted her andwe met one day for cof-fee. We talked about hertime with Amanda. I feltlike I was being given agift from Amanda byway of Barbara—some-thing I never expected tohappen again—a conver-sation with my daughter.Amanda was a wonder-ful writer. She alwayskept a journal and hadstarted a new one shortlyafter her diagnosis. Read-ing Barbara’s narrativewas, for me, like readinganother page in Aman-da’s journal.”
Says Cashavelly,
“When Stephanie con-tacted me, my heart fill-ed with mixed emotionsand fond memories—memories of a special21-year-old patient, herchallenges with leuke-mia, the difficult conver-sation we had at the endof her life, and sayinggood-bye to her.
“I had never sharedthe conversation I hadwith Amanda with hermom. I thought it wouldcause her pain and sad-ness. Occasionally, whenI would see Stephanie inthe halls, memories ofthat conversation wouldcome back to me. Neverdid I imagine this narra-tive would fall into herhands five years later...very close to the anniver-sary of Amanda’s death.
“I have to believe thishappened for a reason.Being able to share thisexperience with Aman-
Emotional coincidencespotlights healing power of
nursing and narratives
I
da’s mom was a gift toher and also to me.”
Barbara Cashavelly’snarrative on caring
for Amanda(Printed with permissionfrom Stephanie Edwards)
My name is BarbaraCashavelly, and I am anurse on the Ellison 14Oncology-Bone MarrowTransplant Unit. Work-ing as an oncology nursecan be challenging, de-manding and very ful-filling. People often askme, “How can you carefor cancer patients? Itmust be so depressing.”
Working with oncol-ogy patients is rewardingand satisfying. The can-cer experience bringsfear, uncertainty, and lifechallenges for patientsand their families. Thedarkness of the unknowncan affect a patient’s
Cashavelly (right) and EdwarCashavelly (right) and EdwarCashavelly (right) and EdwarCashavelly (right) and EdwarCashavelly (right) and Edwardsdsdsdsds
Page 7
May 6, 2004May 6, 2004
strength and sense ofself. It can also have atransforming effect onthe soul, not only for thepatient, but for the nurseas well.
Two months ago, Imet a 21-year-old collegestudent who was admit-ted to the Bone MarrowTransplant Unit for abone marrow transplant.Her name was Amanda.She was a senior at WakeForest University andhad been diagnosed withleukemia in March. Thiswas quite a shock to heras she thought she’d justhad a ‘bad cold’ for twoweeks. When she went tothe infirmary, they didblood tests and discover-ed her nightmare—shehad leukemia.
Initially, Amandawent to another facilityfor treatment, but theleukemia didn’t go intoremission despite threecourses of chemotherapy.She was referred to MGHas a ‘last chance effort.’
When I first met Am-anda, there was a realconnection between us.She was bright and arti-culate. She was easy towork with each day. Weenjoyed each other’scompany and had somecommon interests (talkradio’s Dr. Laura, forinstance). I was amazedat how Amanda dealtwith her disease andtreatment ‘head on.’ Shewrote in her journal everyday and signed eachentry: “IWSL” (I willsurvive leukemia). I shar-ed many experiences
with Amanda, but twowere very special to me.First, was the day shetold me she wanted totake a bath. She was verysick that day. She wasneutropenic, she hadterrible mouth sores, herstrength was down, andshe was receiving num-erous IV drugs and anti-biotics. She required agreat deal of assistancefrom her nurses. Heronly wish was to sit in a“nice hot tub bath.” Thiswasn’t going to be easy.First of all, where was Igoing to find a tub? Andsecond, how would I gether in and out of it safe-ly? But instinct told me Ihad to try my best to giveher this one thing. I knewit would be one of herlast wishes.
I called the Labor &Delivery Unit. They toldme they had a room witha Jacuzzi that wasn’tbeing used. They saidAmanda would be morethan welcome to use it.She was so excited. Itook Amanda to Labor &Delivery along with hermom. We filled the tubwith wonderful, warmwater. With her mom’shelp, we assisted Aman-da into the tub. She wasdelighted! She had thebiggest smile on her face.She said it was “abso-lutely glorious.” Amandasat in the tub for aboutan hour. She thanked mea thousand times thatday. It was very satisfy-ing for me to know I hadmade such a differencein her care.
The other experienceI spoke of was whenAmanda was informedthat her treatment wasn’t
working and she wasgoing to die. This wasone of the most difficultand heartfelt experiencesof my career. After beingtold by the bone marrowteam (including myself),Amanda was devastated.She didn’t want to speakto anyone. I told her tolet me know when shewas ready to talk. Just asI was about to leave atthe end of my shift, hermom came to get me andsaid Amanda wanted totalk to me. I went intoher room. It was just thetwo of us. Through ourtears, we talked for morethan an hour. She askedmany questions. One ofher questions was, “Whatwould you do if it wereyou?” She desperatelyneeded help to make thisdecision. Should she‘give up’ and go homewith hospice? We talkedabout how this wasn’tfair for a 21-year-oldgirl, what it was like todie, what it would belike in heaven, how shebelieved she would be anangel and take care ofpeople after her death.
Amanda asked me togive her an entire syringeof morphine. She said,“Let’s get it over with!Please!”
I told her I wouldn’tgive her the entire syringeof morphine. But I wouldkeep her comfortable andhelp her with any ques-tions. I assured her that Iwould be there for her.
I had never beforebeen asked by a patientto, “get it over with.”The request was distress-ing to me, but it reflectedAmanda’s strength andcourage.
The next day, Aman-da decided to go homewith hospice. I visitedher at home. The minuteI saw her in her roomsurrounded by her familywith the cat curled up onher bed, I knew she hadmade the right decision.She looked peaceful andcomfortable. She was sohappy to see me andthankful for my help.Amanda died five dayslater, surrounded by allthe things she cherished.I will always rememberAmanda, and she willalways have a specialplace in my heart. I real-ize I did make a differ-ence in her care. This 21-year-old college studenttaught me about strengthand courage, and caringfor her helped me be-come a better nurse and abetter person.
Exemplarcontinued from page 6
Comments by JeanetteIves Erickson, RN, MS,senior vice presidentfor Patient Care andchief nurse
This is not only a beau-tiful story and a compell-ing narrative, it’s a won-derful example of the pow-er and timelessness ofstory-telling.
Risk-taking, advocacy,and the ability to be pre-sent to patients in times ofcrisis are hallmarks ofexpert practice. And Bar-bara is an expert. Her careand advocacy extended toStephanie, even after Am-anda’s death. The difficultconversation she had withAmanda at the end of herlife, though poignant, wasrevealed to Stephanie in away that brought her com-fort. What a beautifulstory.
Thank-you, Barbara.
MGH Support ServiceEmployees Grant ProgramThe MGH Support Service Employees GrantProgram is accepting applications from serviceemployees seeking to improve their skills andadvance their careers. This competitive grant
program is available to all non-exempt,benefit-eligible employees who have workedat the MGH for a minimum of two years and
are in good performance standing.
Applications are available at the Training &Workforce Development Office, Human
Resources offices on White 14, 75 BlossomCourt, and 149 Charlestown Navy Yard, 7th
Floor. The deadline for submitting applicationsis June 11, 2004, for financial assistance forfall, 2004, and spring, 2005. Applicants for
the grant program are encouraged to attenda series of career-development workshops
on opportunities in health care at MGH,being held April–June.
For more information, contact Lidia Rosado at 724-3368 or Helen Witherspoon at 726-1700; or visit:
http://is.partners.org/hr/affiliates/mgh/
Page 8
May 6, 2004May 6, 2004
ursing questionsat the bedside real-ly do have the abi-
lity to changepractice. This has neverbeen more evident thanin the recent developmentof oral care guidelines.Guidelines were draftedin response to questionslike, “How can we helpprevent ventilator-ac-quired pneumonia?”“How can we minimize apatient’s risk for aspira-tion?” “What are the bestways to perform oralcare?”
One of the roles of aclinical nurse specialist(CNS) is to enhance pa-tient care using an evi-dence-based practicemodel. From nurses’questions and bedsideobservations, it becameclear there was a need todevelop oral care guide-lines. When changes inpractice are necessary,certain steps contributeto a seamless implemen-tation of those changes.
The first step in de-veloping guidelines isidentifying the clinicalproblem and determin-ing its priority for prac-tice change.
Mentoring is an im-portant part of the CNSrole, so I enlisted theassistance of Universityof Massachusetts mas-ter’s candidate, Eric Wat-son. Eric was interestedin the CNS role and theprocess of practice change.Together we took thequestion of oral care
guidelines to the NursingPractice Committee forvalidation. There wasconsensus among com-mittee members that thiswas a hospital-wide pa-tient need. The impact ofgood oral care on theprevention of ventilator-acquired pneumonia andother conditions wasrecognized by the com-mittee. Many questionswere generated concern-ing best-practice approa-ches. A presentation byTessa Goldsmith, SLP,speech language pathol-ogist, confirmed the needfor a comprehensive andcollaborative approachto oral care.
The second step indeveloping guidelines isa literature search toevaluate existing evi-dence to supportthe change
Good oralcare preventsbacterial colon-ization in themouth. Beforebacteria can col-onize they mustadhere to oro-pharyngeal tis-sue. The mostcommon meansof acquiring no-socomial pneu-monia is aspir-ation of oropha-ryngeal secre-tions. Nosoco-mial pneumoniaranks second inmorbidity andfirst in mortality
among nosocomial infec-tions in the United States.Ventilator-acquired pneu-monia contributes toincreased lengths of stayin intensive care units byfive to seven days andadds billions of dollarsto the overall cost ofhealth care. Whetherintubated or dysphagic(unable to swallow) dueto stroke, reducing thenumber of micro-or-ganisms in the mouthcan reduce the risk ofbacteria spreading to thelungs. Many researcharticles have been pub-lished supporting theneed for oral care guide-lines to prevent ventila-tor-acquired pneumonia.These findings were in-corporated into the newguidelines.
Collaboration is animportant part of imple-menting any practicechange.
It’s important to iden-tify other disciplineswho will be instrumentalin supporting the newpractice. Speech Lang-uage Pathology was in-strumental in creatingthe oral care guidelines.Speech language patho-logists identified a needto address the oral careof our patients and aremajor stakeholders in theimplementation process.Careful review by dis-ciplines that have exper-tise in the area of prac-tice under considerationis invaluable.
Information aboutdaily oral assessmentwas incorporated to as-sist nurses in their evalu-ation of patients’ needs.Pharmacists, infectioncontrol practitioners,nurse managers, nursingsupervisors, and staff
Evidence-based, collaborativepractice in the CNS role
—by Mary McKenna Guanci, RN,neuroscience clinical nurse specialist
Nnurses all help communi-cate the practice change.Clinical specialists playan important role in im-plementing practicechanges in patient careareas. Physician groupsare introduced at the unitlevel. Evaluation of newguidelines is ongoing. Asyou can see, nurse-driv-en, collaborative, evi-dence-based practicereally is possible.
An overview of the neworal care guidelines
Purpose:To ensure appropriate,effective oral care is ad-ministered to all patientsat risk for developingnosocomial pneumoniaor ventilator-associatedpneumonia.
Risk factorsEndotracheal tubeTracheostomyDysphagiaNGT/G-tubeNPO and/or dry mouthcontinued on next page
Mary McKenna Guanci, RN (center), with nursemanager, John Murphy, RN; and speech-language
pathologist, Audrey Kurash Cohen, SLP
May 6, 2004
Page 9
May 6, 2004
Next Publication Date:May 27, 2004
Published by:Caring Headlines is published twice eachmonth by the department of Patient Care
Services at Massachusetts General Hospital.
PublisherJeanette Ives Erickson RN, MS,
senior vice president for Patient Careand chief nurse
Managing EditorSusan Sabia
Editorial Advisory BoardChaplaincy
Mary Martha Thiel
Development & Public Affairs LiaisonGeorgia Peirce
Editorial SupportMarianne Ditomassi, RN, MSN, MBAMary Ellin Smith, RN, MS
Volunteer, Medical Interpreter, Ambassadorand LVC Retail Services
Pat Rowell
DistributionPlease contact Ursula Hoehl at 726-9057 for
all issues related to distribution
Submission of ArticlesWritten contributions should be
submitted directly to Susan Sabiaas far in advance as possible.
Caring Headlines cannot guarantee theinclusion of any article.
Articles/ideas should be submittedin writing by fax: 617-726-8594or e-mail: [email protected]
For more information, call: 617-724-1746.
Please recycle
Decreased LOC or decreasedmental statusMechanical ventilationOxygen therapyAny potential for aspirationSevere dysarthria
Important considerations:A soft toothbrush is the mosteffective way to control dentalplaque. Bacteria commonlyassociated with nosocomialpneumonia are found in den-tal plaque and can become aproblem within 48 hours.Foam swabs are ineffectivefor cleaning teeth and con-trolling plaque.Lemon glycerin swabs are noteffective for cleaning or mois-turizing the mouth and shouldnot be used. In fact, lemonglycerin is harmful. It reducesthe oral pH to below the nor-mal level. Acidic saliva irri-tates oral mucus, decalcifiesteeth, increases dryness of themouth, and increases the riskof dental decay.Alcohol-based mouth rinseshave a drying effect on mucusand should be avoided. Wateror saline should be used forrinsing.Chlorhexidine (Peridex) is anon-alcohol mouth rinse thatreduces plaque and may re-duce the risk of nosocomialpneumonia.
Practice policy:Patients will have a mouthassessment every two-fourhours or more frequently ifdeemed necessary by thenurse. Assessment is bestcompleted with a flashlightand tongue depressor.Patients will have oral careevery two-four hours to en-sure teeth are free of plaqueand to clean and moisten oralmembranes and lips.
Patients’ teeth will be brushedat least every shift using Sagetoothette swabs unless it iscontra-indicated or couldcause harm (i.e., bleeding,gingivitis, low platelets).Lemon glycerin swabs willnot be used to moisten mouth.Chlorhexidine (Peridex) willbe used twice a day for oralcare. A physician’s order mustbe obtained prior to usingPeridex. Do not add any fla-vorings, mouthwash, or med-ications to the chlorhexidine.Do not initiate this protocol
on any patient who has aknown chlorhexidine al-lergy or sensitivity.If using oral Nystatin, donot administer within twohours of (before or after)using chlorhexidine.Continue this oral-careroutine until patients areextubated and able tobrush their own teeth andmanage their own secre-tions.
Documentation:Document oral care on theflow sheet or progress notes.
For more information onoral care guidelines, callMary Guanci at 4-7242.
Clinical Nurse Specialistcontinued from previous page
On-line updates for theClinical Recognition Program
For up-to-date information and changes regarding thesubmission process and preparation for the ClinicalRecognition Program, visit the new Update section
on the Clinical Recognition Program website.
Go to: http://pcs.mgh.harvard.edu; click on ClinicalRecognition Program; click on Program Updates
Summer Jobs Programstwo Community Benefit youth-employment programs may
be the solution to your vacation coverage this summer.
SummerWorksA career-exploration, summer-internship program for
graduating eighth-graders from the Timilty Middle Schoolin Roxbury. Now in its sixth year, SummerWorks combines
weekly interactive workshops with hands-on work experience.Students spend 23 hours per week at the worksite.
For information, call 617-445-5712.
Jobs for Youth (J4Y)For more than a decade, MGH has provided Boston-
area youth with part-time (25 hours per week) employment.Jobs for Youth links SummerWorks alumni and students
from East Boston High School to dynamic job opportunitiesat MGH. The program combines professional-development
workshops with real work experience to help studentsmake informed career decisions.
For information, call 4-8326.
The Summer Jobs program is a school partnership initiativethrough the MGH Community Benefit Program
Page 10
May 6, 2004May 6, 2004
about providing safepatient care. Not longago, we assumed that ifpractitioners were care-ful, smart, and thought-ful, they wouldn’t makemistakes. But mistakescan happen in every in-dustry and every settingdespite measures takento prevent them. Certain-ly, health care profession-als should be careful,vigilant, and held respon-sible for their actions,but assigning blame forerrors does little to makesystems safer or preventsomeone else from mak-ing the same mistake.(Institute of Medicine,To Err is Human: Build-ing a Safer Health Sys-tem). The best way toprevent accidents is tochange systems, not indi-viduals.
The Quality Commit-tee identifies opportuni-ties to improve systemsto improve patient careand link key stakehold-ers with performance-improvement initiatives.Members of the commit-tee develop knowledgeand skill at using thequality-improvementprocess. The committeeworks closely with JoanFitzmaurice, RN, direc-tor of Quality & Safety.Committee co-chairs,Anne Eastman, RN, andPat Wright, RN, repre-sent Patient Care Serviceson the state-mandatedPatient Care AssessmentCommittee that monitors
quality at MGH. TheQuality Committee usesthe quality-improvementprocess and analysis ofhospital-wide adverseevents to identify high-risk or problem-proneaspects of care in clinicalsettings. Systems analy-sis and improvementrecommendations arereferred to appropriatework groups for actionand/or implementation.
The Quality Commit-tee serves as an expertresource to many groups.This year, members con-tinued to work on im-proving medication ad-
Collaboration: the key toquality patient care
—by Karen Lipshires, RN,member of the Quality Committee
ministration, procure-ment of new and saferbedside commodes, in-fection-control surveil-lance, and the Hand Hy-giene Improvement Ini-tiative. The Quality Com-mittee worked in collab-oration with the NursingPractice Committee re-garding transfusion prac-tices, occupational-healthissues, and care of thebariatric patient.
QualityQuality
abels on IVmedications—
who decides whatinformation
is included? Patty,from the Surgical Inten-sive Care Unit, says she’dlike to see informationabout the patient. Diane,from Blake 12, feels it’simportant to indicatewhether the bag containsthe total daily dose or asingle dose for the day.Ann, from Bigelow 14,wants information on thelabel to be re-organized.
These are exactly thekind of comments theQuality Committee lovesto hear. Committee mem-bers listen to ‘what’swrong’ and explore waysto improve systems tosupport safe patient care.Recently, changes weremade to IV labels to pro-mote greater patient safe-ty. Changes were basedon recommendationsfrom nurses and collabo-rative governance com-mittees (including thePractice Committee, theQuality Committee, andothers). The PharmacyNursing PerformanceImprovement Committee(PNPIC), co-chaired bySteve Haffa, RPh, andKathy Carr, RN, develop-ed a new format for IVlabels that allows bothNursing and Pharmacyto include informationthey consider necessaryfor safe medication ad-ministration.
This change reflects anew way of thinking
L
If you identify a safe-ty concern regardingsystems or equipment,please contact the Qua-lity Committee by e-mail(listed as PCS QualityCommittee in the Out-look directory). For moreinformation about theQuality Committee orcollaborative governancevisit the website: http://pcs.mgh.harvard.edu/CCPD/cpd_govern.asp.
Quality on-lineTo learn more about quality, visit these websites:
QualityHealthcarehttp://www.qualityhealthcare.org
Agency of Healthcare Research and Qualityhttp://www.ahrq.gov/
Institute for Safe Medication Practiceshttp://www.ismp.org/>
Educational OfferingsEducational Offerings May 6, 2004May 6, 2004
2004
2004
For detailed information about educational offerings, visit our web calendar at http://pcs.mgh.harvard.edu. To register, call (617)726-3111.For information about Risk Management Foundation programs, check the Internet at http://www.hrm.harvard.edu.
16.8for completing both days
Advanced Cardiac Life Support (ACLS)—Provider CourseDay 1: O’Keeffe Auditorium. Day 2: Wellman Conference Room
May 14 and 178:00am–5:00pm
Pediatric Advanced Life Support (PALS) Re-Certification ProgramWellman Conference Room
- - -May 147:30am–12:30pm
Cancer Nursing: Caring Through Evidence-Based PracticeO’Keeffe Auditorium
TBAMay 178:00–4:30pm
Building Relationships in the Diverse Hospital Community:Understanding Our Patients, Ourselves, and Each OtherTraining Department, Charles River Plaza
7.2May 198:00am–4:30pm
USA Educational SeriesBigelow 4 Amphitheater
- - -May 191:30–2:30pm
BLS Certification for Healthcare ProvidersVBK601
- - -May 208:00am–2:00pm
Workforce Dynamics: Skills for SuccessTraining Department, Charles River Plaza
TBAMay 208:00am–4:30pm
CPR—American Heart Association BLS Re-CertificationVBK 401
- - -May 247:30–11:00am/12:00–3:30pm
CPR—Age-Specific Mannequin Demonstration of BLS SkillsVBK 401 (No BLS card given)
- - -May 258:00am and 12:00pm (Adult)10:00am and 2:00pm (Pediatric)
Natural Medicines: Helpful or Harmful? Researching theLiterature on Herbs and Dietary SupplementsClinics 262
1.8May 184:00–5:30pm
Contact HoursDescriptionWhen/Where
Intermediate Respiratory CareRespiratory Care Conference Room, Ellison 401
TBAMay 258:00am–4:00pm
New Graduate Nurse Development Seminar IITraining Department, Charles River Plaza
5.4 (for mentors only)May 268:00am–2:30pm
Nursing Grand Rounds“Health Literacy.” O’Keeffe Auditorium
1.2May 271:30–2:30pm
CPR—Age-Specific Mannequin Demonstration of BLS SkillsVBK 401 (No BLS card given)
- - -June 18:00am and 12:00pm (Adult)10:00am and 2:00pm (Pediatric)
Bio-Therapy ProgramNEMC Wolff Auditorium
TBAJune 18:00am–4:30pm
CPR—American Heart Association BLS Re-CertificationVBK 401
- - -June 37:30–11:00am/12:00–3:30pm
Hypertensive Disorders in PregnancyO’Keeffe Auditorium
TBAJune 48:00–4:30pm
New Graduate Nurse Development Seminar ITraining Department, Charles River Plaza
Send returns only to Bigelow 10Nursing Office, MGH
55 Fruit StreetBoston, MA 02114-2696
First ClassUS Postage PaidPermit #57416
Boston MA
n Friday, April 2, 2004, MGH employeescame together in the Maxwell & EleanorBlum Patient and Family Learning Center(PFLC) to celebrate the fifth anniversary of
this invaluable resource. MGH president,Peter Slavin, MD; senior vice president for PatientCare, Jeanette Ives Erickson, RN; patient educationspecialist and learning center manager, Taryn Pit-tman, RN; and Eleanor Blum all were in attend-ance. After brief comments by invited guests, in-cluding PFLC volunteer, Joseph Terrell, the recep-tion culminated with the cutting of a cake by Max-well and Eleanor’s daughter, Betty Ann Blum.
