Nursing that changes your world

Sylvia Edwards approached Elicia Jacob with the idea of pursuing baby-friendly designation for UAB Hospital. Becoming a World Health Organization and United Nations Children’s Fund “baby-friendly” hospital is no trivial charge. Hospitals seeking “baby-friendly” designation begin a comprehensive and detailed journey toward excellence in providing evidence-based maternity care. The goal is the achievement of optimal infant feeding and mother/baby bonding that positively impact the overall family dynamic.

Elicia, concerned about the poor health of Birmingham area women, agreed that becoming a “baby-friendly” designated hos-

pital seemed to be a perfect first step toward addressing a community concern. According to Elicia, “what better way to affect those statistics than to start here – in the UAB Women & Infants Center, where life begins?” She and Sylvia secured a “Best Fed Beginnings” grant through the National Institute of Child Healthcare Quality (NICHQ) and together, with the help of an interdisciplinary team, began to revamp UAB’s maternity care services in pursuit of “baby-friendly” designation.

“Baby-friendly” designation is more than a “seal of approval.” It requires extensive engagement and education of the staff. Nurses must have a deep understanding of the benefits of breastfeeding – both to mother and baby. Nurses must be able to share the benefits of breast feeding with new moms and their support persons. Information provided includes the benefits of breastfeeding to: provide irreplaceable nutrients and antibodies; aid in digestion and change over time to match the growing baby’s needs; prevent and reduce the incidence of asthma, obesity, diabetes, and respiratory infections. Sylvia and Elicia are fortunate to work with a team of nurses in the Women & Infants Center who are committed to ensuring that the journey to baby-friendly designation is successful. These nurses are “foot soldiers,” who must be educated, confident, and engaged. Above all, they must tap into their N Power to ensure a strong start and better outcome for UAB’s tiniest patients.

In the creation of this story, we interviewed Sylvia Edwards, RN, MS, APRN, IBCLC RLC, Supervisor, Lactation Services and Elicia Jacob, MSN, RN, PHCNS-BC, Director of Nursing, Women’s Services

ENGAGE

In medical matters of the heart, it is said that time equals muscle. So, when a patient presents with symptoms of a Myocardial Infarction (MI), the sooner a diagnosis is made, the more heart muscle can be saved. At the UAB Emergency Department (UED), the goal for getting an EKG on patients presenting with potential cardiac related symptoms is 5 minutes, which is half of the national benchmark of 10.

Considering the importance of this quality and safety goal, staff nurses Tamra McWaters and Jackie Sabella, now working as Clinical Documentation Specialists, recognized an opportunity to improve accuracy of lead placement and timeliness of EKG collection. They realized the most efficient way to implement a unit-wide change was to enlist the help of their fellow UED Unit-Based Congress members. They presented the issue to the group, and a Professional Action Coordinating Team (PACT) was formed to analyze the problem. Together, they administered quizzes to assess baseline staff knowledge of lead placement, and based on those results, they designed an intervention to improve EKG accuracy.

They also developed a protocol for when to administer EKG’s and by whom, establishing accountability for staff at all levels. Through hands-on staff education, proper lead placement was reviewed and the new collection protocol was initiated. Additionally, unit-wide resources were produced and made readily available.

Before the Unit-Based Congress’ initiative, the UED was averaging a door-to-EKG time of 5 minutes and 38 seconds. After implementation, that time has been reduced by 1 minute 15 seconds to an average of 4 minutes 23 seconds, well within the 5-minute goal. In this case, N Power is all about improvements – improvements that save lives.

In the creation of this story, we interviewed Tamra McWaters, RN, Clinical Documentation Specialist and Jacqueline Sabella, MSN, RN, CNL, Clinical Documentation Specialist

IMPROVE

Patients from an outpatient clinic being admitted to the hospital require special attention to ensure a safe transition between clinic and hospital. Kimberly Turnley, Ginger Locks, and Angela Medici from The Kirklin Clinic of UAB Hospital, identified a potential patient safety risk related to hand-offs between the clinic and the UAB Emergency Department (ED) staff. Together with members of the ED, they assembled a team to iden-tify ways to improve this critical patient transfer.

The team worked together to develop a process to ensure that patients in the clinic in need of admission were safely transported to the ED. Since overcrowding of the ED is common,

facilitating the clinic patient’s assessment on arrival to the ED became the group’s focus. The goal was to make the patient’s visit seamless, even though they had been transported several blocks for continued care. The team reviewed every step of the transfer process in order to ensure continuity of care in the ED. A page in the electronic health record (EHR) was created to detail the specific events leading to the admission. Although they determined that a verbal telephone report was a necessary and critical step, the electronic report became something the RN in the ED could refer to at the point of arrival.

The team reviewed case studies of previous patients who were transferred to the ED environment. The retrospective review indicated that some of the patients were too sick to be transported. Based upon this revelation, the team determined the need for an RN from the ED to go to the clinic to triage the patient there – prior to making the decision to transport them. After assessment, the ED nurse communicates the patient’s condition with the ED charge nurse. The ED nurse also can communicate the urgency of the patient’s condition with the Nursing Resource Coordinator to identify the patient as a priority for the next available inpatient room.

It’s been a year-long effort. They still hold monthly meetings to evaluate efficacy of patient hand-off. But one thing’s clear: N Power is what’s behind better care of patients being admitted to the hospital from the clinic.

In the creation of this story, we interviewed Kimberly Turnley, MSN, RN, Senior Director, TKC of UAB Hospital Division of Clinical Services, Ginger J. Locks, BSN, RN, Director, TKC of UAB Hospital Clinical Services, Primary Care, and Angela Medici, BSN, RN, Patient Safety Coordinator

ENTRUST

When the Stroke/Surgical Step Down unit moved from a 20-bed unit in UAB Medicine’s Spain Wallace building to a 28-bed unit in the newer UAB North Pavilion, they went from an ICU environment with glass windows and doors on patient rooms – where they could look in and see their patients – to rooms with windowless walls and solid doors. Stroke patients have trouble dealing with hospital surroundings, many of them unaware of their environments and their movements. Consequently, stroke patients tend to be at higher risk of falling than other patient populations. As the RNs and staff became accustomed to their new unit, not having the glass windows and doors was disconcerting.

Assistant Nurse Manager Brett Burnell, and his colleague, Jason Williams, RN, were mulling the problem over. In one of those “aha” moments, they came up with a simple, elegant solution to not being able to look in on their patients from the nurses’ station or hallway. The next week, Brett’s Nurse Manager, Jill Stewart, found a baby monitor from Target in her in-box with a note from Brett: “Have we ever thought about using these?” Jill immediately recognized the potential and applied for a UAB Medicine innovation grant. Her application came through with flying colors.

The unit now has seven baby monitors in use. Nurses identify the patients with the greatest fall risk (they call them their “super fallers”) and, with family permission, place the video camera end of the monitor in the room. The receiving end can be carried around or monitored from the nurses’ station. The monitors were an instant hit. Now the nursing staff can’t imagine not having them.

The number of falls on the unit has been more than halved from a rate of 5.09 falls per 1,000 patient-days to 2.29 falls per 1,000 patient days. And, as of this writing, there have been 250 “near misses” where a nurse actually went into the room because of something he or she saw on the monitor. And UAB is looking at employing the monitors on other units where patients stand a high risk of falling. This is N Power at work in the form of an ingeniously simple solution to a challenging problem.

In the creation of this story, we interviewed Jill Stewart, DNP, RN, CNOR, Nurse Manager and Anthony “Brett” Burnell, BSN, RN, Assistant Nurse Manager

INGENIOUS

Pressure ulcers have consistently been a challenge for healthcare providers – now even more so with the ever evolving regulatory changes that have been put in place for treating ulcers acquired by patients under their care. They’re a quality concern at the forefront of every nurse’s mind.

Former Chief Nursing Officer, Velinda Block, DNP, RN, NEA-BC, declared 2013 “The Year of the Pressure Ulcer”. In response, the Pressure Ulcer Prevention (PUP) Team, established in 2012 and made up of Wound Ostomy and Continence Nurses (WOCN) Karen Edwards, BSN, RN, MSS, CWOCN, Kelly Suttle, BSN, RN, CWOCN, Sharon White, BSN, RN, CWOCN, Catrice Potts, Najla Washington, and Amy Armstrong, rolled out a pressure ulcer bundle – to help educate staff and standardize the prevention and treatment of pressure ulcers. This bundle of evidence-based practices helps bedside nurses accurately evaluate their patients’ risk, address problems before they occur, and treat pressure ulcers effectively.

The pressure ulcer bundle requires nurses to document and assess patients’ skin upon arrival to the unit and daily thereafter – an important step given that an undocumented or incorrectly documented ulcer, even if it existed prior, is credited to the hospital. Nurses assess their patients’ pressure ulcer risk based on the Braden Scale, which defines characteristics in patients more likely to develop pressure sores. When inputting results from the assessment into the patient’s medical record, a specially developed power plan will fire to alert the staff nurse if the patient is at risk. The bundle also describes steps required to prevent or treat pressure ulcers, depending on the patient. The PUP Team also pre-scribes standardized equipment and supplies that must be on pressure ulcer treatment carts on every floor, ensuring nurses are always equipped to treat their patients.

Along with the bundle, the PUP team conducts pressure ulcer training that encourages staff nurses to learn more and become unit experts by attending the class. The unit experts then help with training others on their units and conduct quarterly pressure ulcer audits with the WOCNs. Tammy Canter, Nurse Manager of the Nephrology unit, requires her bedside nurses to attend the WOCN Skin Care and Ostomy Care Class and complete online training modules so that all of them have proficiency in prevention and treatment of pressure ulcers. And, like many other units, she’s seen a drop in the incidence of pressure ulcers as a result.

You see, Tammy knows that an ounce of prevention is worth a pound of cure. And the ounce of prevention when it comes to pressure ulcers has come from having unit experts like Disha Amin and Shenika Tucker who are constantly training their colleagues – teaching them how to turn their patients, where their bodies need to be supported, how to “float” their heels, and the like. The results hospital-wide have been great, with a significant drop in hospital acquired pressure ulcers across the board.

In the creation of this story, we interviewed Amy Armstrong, RN, CWOCN, Najla Washington, RN, CWOCN, Catrice Potts, BSN, RN, CWOCN, Tammy Canter, MSN, Nurse Manager, Shenika Tucker, RN, Assistant Nurse Manager, Unit Expert and Disha Amin, RN, Unit Expert

INSTRUCT

Managing patient flow from unit to unit, or – throughput – has many moving parts. For example, if a patient is out of surgery, the unit receiving the patient must know. Environmental ser-vices must clean the room the patient is moving to. The send-ing unit – in this case a surgical unit – must know the room is ready. Transportation must be notified in order to move the patient. And most importantly, the sending unit must give report to the receiving unit detailing the patient’s status.

On W7 North, they admit about 165 patients per month. Lag between when a room was ready and when a patient arrived was often an hour or more. So, in 2013, W7N Nurse Manager, Daran Brown and Assistant Nurse Manager, Bridget McIntyre, were excited to be one of four pilot units in a program to improve patient throughput. Working with the Director of Patient Throughput, Brittany Lindsey, MPA; Supervisor of Patient Flow, Vivian Diggins; and Patient Placement Specialist, Jeanene Myree-Madison, the team analyzed the steps involved in moving patients. There was a 30-minute hold on transfers around 6:30 AM/PM shift changes for fear that quality of patient care would suffer during the hectic transitions. Nurses also had been waiting until rooms were ready before receiving report. The team realized nurses could

receive patient reports from sending units any time – even during shift changes – without sacrificing care. It would require a culture change, but it made sense.

Now, nurses receive sending unit reports when the patient is ready to move – often before the room is clean or even available. Sending units are then notified just as soon as the room is ready through teletracking, and the patients are moved. With Assistant Nurse Managers watching over the quality of care, this culture change has been a huge success, with savings of as much as an hour in transfer time – an hour a patient doesn’t have to wait to be under the care of the receiving unit, and an hour saved that allows the hospital to serve more patients.

In the creation of this story, we interviewed Daran Brown, RN, MBA, Nurse Manager W7N, Bridget McIntyre, BSN, RN and Vivian Diggins, BSN, RN, CCN, Supervisor Patient Flow

INSTEP

On one side of University Boulevard in Birmingham, Alabama is a world-class academic medical center, on the other – a premier school of nursing. UAB Hospital and UAB School of Nursing are partnering to empower and transform the nursing profession. This strategic alignment provides opportunities for nurses at all levels of their careers and generates seminal research into nursing best practices in nursing and health care. Thanks to a clear vision, tenacity, and the pursuit of dialogue, the connection between UAB’s academic nursing partners strengthens nursing care delivery across UAB Hospital and Health System.

As Dean Doreen Harper puts it, “With UAB Hospital on our campus, our students and faculty are uniquely positioned to learn and work in its advanced clinical settings on the leading edge of practice. Together, UAB Hospital and the UAB School of Nursing are partnering to create a seamless transition from academia to clinical practice.” For example, UAB School of Nursing instructor, Penni Watts, MSN, RN, works collaboratively with the UAB clinical simulation enterprise which offers collaborative clinical simulation scenarios in high-stakes situations for nursing and medical students. Donna Brown Banton Endowed Professor, Pat Patrician, PhD, RN, FAAN, and Assistant Professor Angela Jukkala, PhD, RN, sit on the hospital’s shared governance board and have implemented projects in partnership with the hospital to improve quality and patient safety.

“Having an exceptional school of nursing is a huge benefit on the clinical side as well,” says Terri Poe. A collaborative team including Connie White-Williams, PhD, RN, FAAN-LHL; Associate Dean for Clinical Affairs and Partnerships Cindy Selleck, PhD, RN, FNP; and Assistant Dean for Clinical Affairs and Partnerships Maria Shirey, PhD, MBA, RN, FAAN, is working to help UAB nurses return to school for their advanced nursing degrees. “That’s a significant priority for us,” says Poe. “Better education for our nurses ultimately means better outcomes for our patients.”

Perhaps most compelling of all, collaborative research being conducted between the two organizations is transforming nursing practice. UAB School of Nursing Assistant Professor Shea Polancich, PhD, RN, and UAB Hospital nurses are partnering to examine quality practices. Numerous collaborative grants have been written, uniting clinical and academic expertise in the pursuit of higher standards of care and world-changing best practices.

One way UAB Hospital and UAB School of Nursing have stimulated dialogue is through the Leadership in Nursing Council (LINC). Over the past five years, the two have developed this relationship to open doors for RNs seeking their BSN and for other nurses seeking their master’s and doctoral degrees. A key part of the LINC relationship has been the alignment with hospital and health system priorities of multiple evidence-based clinical scholarship projects each year by UAB Hospital’s nurses that have returned to school that not only fulfill their educational requirements but that also

improve care for UAB’s patients and their families. Another key to the seamless dialogue is the interweaving of UAB School of Nursing faculty and UAB Hospital nurses across both platforms. Many of the school’s faculty practice in the hospital and many of the hospital’s nurses serve as adjunct instructors across all of the school’s programs. Together, the UAB School of Nursing and the nurses of UAB Hospital are changing the world through better patient- and family-centered care.

In the creation of this story, we interviewed Terri Poe, DNP, RN, NE-BC, Interim Chief Nursing Officer, UAB Hospital and Doreen Harper, PhD, RN, FAAN, Dean, UAB School of Nursing

INTEGRATE

The Surgical Care Improvement Project (SCIP) has preventive measures, designed to reduce surgery-related infections and morbidity. These pre and postoperative steps include procedures such as removing urinary catheters within 48 hours of surgery, administering antibiotics inside an hour pre-surgery, and ending antibiotics within 24 hours afterwards. Other steps include administering blood thinners and putting compression hose on patients to avoid deep vein thrombosis (DVTs), as well as warming them to prevent infections that arise when body temperatures fall below a given threshold. These are evidence-based practices that improve quality of care and outcomes.

SCIP team members, Doreni Fleming, Elisa Mejia, Michael Fox, and Debbie Cook will tell you that SCIP compliance requires a team, and more than a little creativity. At UAB, nurses are empowered. For example, a surgical checklist, signed off on by the surgeon, bundles procedures in a single “Surgical Powerplan.” Unless the physician sees reason to vary from it, listed procedures are automatic. Based on this nurse-driven protocol, UAB nurses may remove urinary catheters if they haven’t been removed within 48 hours without written orders. Laminated antibiotic cards describe default antibiotics for specific procedures, and if the physician signs off on the “powerplan,” the Certified Registered Nurse Anesthetist administers the antibiotic.

The SCIP team at UAB Hospital-Highlands has led the charge of improving surgical care measures and continues to fine tune SCIP procedures house-wide. They follow evidence-based research and improve current best practices at UAB. “Bair Paws,” blankets that blow warm air are used to warm patients, are stocked in the ORs and prophylactic antibiotics are being administered within 30 minutes of surgery because the team has determined that to be best evidence-based practice. Bottom line, UAB patients are experiencing better outcomes because UAB’s nurses are empowered. And that’s the very definition of N Power.

In the creation of this story, we interviewed Doreni Fleming, BSN, RN, MSHA, Nurse Manager 5Main, Elisa Mejia, MSN, RN, CNOR, CIC, Perioperative Quality Improvement Nurse, Michael Fox, MSN, RN, CNOR, Advanced Nurse Coordinator and Debbie Cook, MSN, RN, NE-BC, FACHE, Associate Administrator for Patient Care Services at UAB Hospital-Highlands

EMPOWER