Nursing Annual Report 2015-16

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Table of Contents

A Message from the Chief Nursing Officer .....................................................................3

About Winchester Medical Center .................................................................................4

The Magnet Model .........................................................................................................6

Transformational Leadership ..........................................................................................8

Structural Empowerment .............................................................................................13

Exemplary Professional Practice ..................................................................................22

New Knowledge, Innovations & Improvements ...........................................................26

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As Vice President and Chief Nursing Officer for Winchester Medical Center, I am proud of our achievements and the contributions from our nurses.

We continue to expand our footprint through the many roles we serve for our community. Our team of certified nurses continues to expand in number and breadth. Faith Community Nursing is the most recent addition to our collection of certifica-tions: we now have more than 50 faith community nurses among us, and they are a powerful force to help families have important conversations at home.

I am proud of the strides we’ve made in academic progression. The decision to return to school is a hard one, but our organization has removed as many return-to-

school barriers as possible. Supported by all levels of the organization from the board to the bedside, we have provided varied financial and logistical support to meet the needs of our nurses who are returning to school. Our academic partners have also come to the table to shape their programs and offerings based on our students’ feedback. I am inspired by our nurses’ stories reflecting on their learning journeys, and my occasional glimpses from the back of the classroom. Winchester Medical Center and our patients are benefitting from our students’ work. This year’s graduation ceremony at Winchester Medical Center, hosted during National Nurses Week, was a moment to showcase the dedication and pride of our students.

As demand for new and innovative clinical services evolves, our nurses have responded with evidence- based practice using the best available research evidence to design our services, develop clinical expertise and foster a superior patient experience. To that end, we tested two new positions to support and accelerate our Performance Improvement and Research: a research intern and embedded Performance Improvement nurses. Each of these nominated nurses work a portion of their week in their unit of origin and spend the remainder of their time in PI or research. The benefit of this model aligns with Magnet’s Structural Empow-erment component and the High Reliability tenet of Deference to Expertise.

As our organization changes, we have also changed our leadership structure to accomodate the program-matic demands and the shift in our workforce patterns. We have successfully developed successor plans for key roles and recently promoted rising directors. We launched a more robust preceptor plan to support our onboarding and career progression. We have benefited from the transformational leaders that have fostered and supported these changes. This has enabled us to adjust the span of control where needed, identify and promote our rising talent and create opportunity at all levels of Winchester Medical Center.

This is an exciting time in Winchester Medical Center’s history and I am proud to be a part of this nursing team, which is making a difference for our community — one patient at a time.

My best,

Anne Whiteside Vice President/Chief Nursing Officer Winchester Medical Center

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About Winchester Medical Center

Winchester Medical Center is the hub of Valley Health’s network of six not-for-profit hospitals and related healthcare entities, and serves as a regional referral center for citizens in an 18-county service area that includes the northern Shenandoah Valley of Virginia, the Eastern Panhandle of West Virginia and western Maryland. As an award-winning 455-bed hospital, Winchester Medical Center offers a remarkable breadth of specialty services for a community of this size, and continues to bring high quality care and advanced treatments to the patients and communities we serve. For more than a century, our team of outstanding clinicians has been committed to ensuring that every patient receives excellent care — care that is timely, safe, supportive and patient-centered.

As the region’s tertiary referral hospital, Winchester Medical Center is a:• Level II Trauma Center• Chest Pain Center with Percutaneous Coronary Intervention • Advanced Primary Stroke Center• Level 4 Epilepsy Center• Level III Neonatal ICU• Magnet® Designated Hospital

Winchester Medical Center received numerous awards in 2015 and 2016, including a 3-Star rating for heart surgery (CABG) by the Society of Thoracic Surgeons, an “A” for patient safety (Hospital Safety Score) from the Leapfrog Hospital Safety Group and recognition as a Best Regional Hospital by U.S. News and World Report.

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The Magnet Model provides a framework to achieve excellence in nursing practice and serves as a road map for organizations seeking Magnet® Recognition.

ANCC Magnet-recognized organizations serve as the source of knowledge and expertise for the delivery of nursing care globally. Grounded in core Magnet principles, they will be flexible and constantly strive for discovery and innovation. They will lead the reformation of health care, the discipline of nursing, and care of the patient, family, and community.

I. Transformational Leadership Nursing leaders at all levels of a Magnet-recognized organization must demonstrate advocacy and support on behalf of staff and patients to transform values, beliefs, and behaviors. The CNO must be strategically positioned within the organization to effectively influence other executive stakeholders, including the board of directors/trustees.

Nursing’s mission, vision, values, and strategic plan must align with the organization’s priorities to improve performance, wherever nursing is practiced.Mechanisms must be implemented for evidence-based practice to evolve and for innovation to flourish. As a result, nurses throughout the orga¬nization should perceive their voices are heard, their input is valued, and their practice is supported.

II. Structural EmpowermentNurses throughout Magnet-recognized organi¬zations are involved in shared governance and decision making structures and processes to es¬tablish standards of practice and address oppor¬tunities for improvement. Nurse leaders serve on decision making bodies that address excellence in patient care and the safe, efficient, and effec¬tive operation of the organization.

The flow of information and decision-making is multidirectional among professional nurses at the bedside, leadership, interprofessional teams, and the chief nursing officer.

The Magnet Model

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Nurses and nurse leaders develop strong partner¬ships with community organizations to improve patient outcomes and advance the health of the communities they serve. This is accomplished through the organization’s strategic plan, struc¬ture, systems, policies, and programs.

III. Exemplary Professional Practice Exemplary professional practice in Magnet-rec¬ognized organizations is evidenced by effective and efficient care services, interprofessional collaboration, and high-quality patient outcomes. Magnet nurses partner with patients, families, support systems, and interprofessional teams to positively impact patient care and outcomes. In-terprofessional team members include but are not limited to personnel from medicine, pharmacy, nutrition, rehabilitation, social work, psychology, and other professions that collaborate to ensure a comprehensive plan of care. Collegial working relationships within and among the disciplines are valued and promoted by the organization’s leadership and its employees.

The achievement of exemplary professional practice is grounded in a culture of safety, quality monitoring, and quality improvement. Nurses collaborate with other disciplines to ensure that care is comprehensive, coordinated, and monitored for effectiveness through the quality improvement model.

Nurses at all levels analyze data and use national benchmarks to gain a comparative perspective about their performance and the care patients receive. Magnet organization data demonstrate outcome measures that gen-erally outperform the benchmark statistic of the national database used in patient and nurse-sensitive indicators.

IV. New Knowledge, Innovations & Improvements Magnet-recognized organizations integrate evi¬dence-based practice and research into clinical and op-erational processes. Nurses are educated about evidence-based practice and research, enabling them to appropriately explore the safest and best practices for their patients and practice environment and to generate new knowledge.

Innovations in patient care, nursing, and the prac¬tice environment are the hallmark of organizations receiving Magnet recognition. Establishing new ways of achieving high-quality, effective, and efficient care is the outcome of transformational leadership, empowering structures and processes, and exemplary professional practice in nursing.

V. Empirical Outcomes The empirical measurement of quality outcomes related to nursing leadership and clinical practice in Magnet-recognized organizations is imperative.

Outcomes are categorized in terms of clinical outcomes related to nursing, workforce outcomes, patient and consumer outcomes, and organiza¬tional outcomes. These outcomes will represent the “report card” of a Magnet-recognized organization, and a simple way of demonstrating excellence.

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Transformational Leadership

Project Follow it Through (F.I.T.) on the Road to Excellence

The Project F.I.T. (Following It Through) rapid cycle change process began in October 2014 and contin-ues to the present with Emergency Department staff-and-physician-led workgroups that are engaged and committed to creating a patient-centric environment with improved clinical outcomes. The workgroups established during Project F.I.T. consisted of bedside staff members, patient advocates, bedside nurses and physicians.

Over a six-month period, four different workgroups approached change in a methodical and structured manner. Through a series of steps — identification, measurement, prioritization, redesign, operation, valida-tion and execution — the workgroups were able to test different throughput strategies to ensure that the fi-nal process implementation fit the culture and patient care model. The workgroups examined opportunities pertaining to patient throughput and how to remove barriers in order to create efficient and effective patient flow. They also reeducated staff on how to appropriately communicate patient acuity in a consistent and standard language. The successes of these workgroups included the development of a Rapid RN, estab-lishment of our Rapid Assessment Unit (RAU), definition of new roles for Flow Coordinator and Throughput Nurse, and consistent utilization of a validated triage acuity system (ESI).

At the end of the six month period from January to June 2015, the team was able to implement processes that decreased arrival to triage time by 82%, arrival to provider time by 39% and arrival to discharge home by 18%. Due to the outstanding teamwork and success of Project F.I.T., Emergency Department patient satisfaction improved significantly from the 44th percentile in Q4 2014 to the 72nd percentile in Q2 2015. Emergency Department Leadership continues to track the metrics for 2016 and remains focused on main-taining the improvements made as a result of the F.I.T. Project.

This project was a systematic and methodical approach to change that began by utilizing multidisciplinary input from all staff members in the Emergency Department. Staff members supported the Winchester Med-ical Center Emergency Department’s goal to promote high quality, efficient healthcare for the unscheduled patient needs in our region. This project turned into an organizational initiative to enhance the patient expe-rience. Over the course of this project, the Emergency Department has improved throughput from the time of the patient’s arrival to discharge home. However, for many of our patients the journey does not end in the Emergency Department. More than 60% of our patient admissions begin in our Emergency Department; therefore, the next logical step after improving Emergency Department throughput was to analyze inpatient throughput, from the time of admission to discharge home. A collaborative workgroup of inpatient and emergency nurses, clinical managers and Epic staff have come together to improve the patient experience from admission to discharge. This multi-faceted process has included many moving parts that the team has analyzed and initiated improvement efforts upon. Through assessment and opportunity identification the team reviewed the process from Emergency Department to inpatient area.

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Arrival to Triage & Provider

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Emergency Department Patient Satisfaction Scores

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Multidisciplinary Efforts to Change Blood Glucose Notifications

In 2015, multiple hypoglycemic events required the assistance of the Rapid Response Team at Winchester Medical Center. The nurses in these cases had not known the serum lab glucose value drawn during the early morning hours was significantly low. At this time, our laboratory only called on the critical values of 40 and below, and 550 and above. Nurses at the Nursing Practice Council questioned why they were not noti-fied at a treatable value instead of a critical value. The existing practice was not preventing harmful events due to hypoglycemia.

The ProblemSerum glucose critical values were called to nursing by lab only for values <40 and >550. Critical values for physician notification are determined by the physicians and the laboratory director of the health system.

The treatable value for hypoglycemia according to system policy is <70. Nursing is expected to treat the hypoglycemia according to policy. Nursing was never informed when the test was in the treatable range.

Why the change in practice? Routine daily lab draws occur in the early hours of the morning. Lab did not notify the RN of blood sugar values between 41 and 69 prior to the change in practice. Depending on workload, the treatable value may not have been noted by clinical staff. The patient could ultimately worsen before the value was ever seen by the direct care clinician. At this time, emergent hypoglycemic events were too fre-quently reported on the morning safety call. Resuscitative-type events could ultimately lead to a longer length of stay and patient and family dissatisfaction.

This project was a performance improvement initiative, and did not require approval from the Win-chester Medical Center IRB. Data collection was done as a retrospective review.

In 2015, four months of inpatient serum blood glucose values drawn by phlebotomy staff were eval-uated for the number of blood sugar values at 70 or less. The total number of serum blood glucose tests between July and October 2015 amounted to 36,368. The time of day the samples were drawn was also considered, with 35,014 samples being drawn from 0100 to 0700 hours. 96.3% of all serum glucose values were drawn and resulted during this time frame. Time and task restraints could keep the nurse from viewing routine lab results, especially those that were low, but not critical.

In 2015, in-hospital morbidity related to low blood glucose was reported on the daily safety call with significant frequency. Hypoglycemic events contributing to longer inpatient length of stay were occur-ring several times each week. Though the number of events was not significantly high, reports of one or more per week were concerning to the nursing staff. We considered even one event to be too many. Our patients’ hospital course had a failure, and something needed to be done.

According to our lab director, there is only one value that can be called to licensed staff. Historically, it has been the “critical value.” She made sure that Nursing was aware that if the value was changed, it had to be approved by the medical community within the organization.

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Our nurses on the Nursing Practice Council sought out physicians, NPs and PAs to address whether they would like nurses to be notified before a patient became unresponsive, such that the nurse could prevent an emergent hypoglycemic event. All practitioners preferred that the nurse be notified of the treatable value, though they did not want to be called for every treatable serum blood glucose.

This endeavor went through Diabetes Management and a nurse-driven diabetes work group, as well as all physician groups, physician committees, and the Board of Directors.

Nursing has been impacted significantly since the change in notification of the treatable glucose level. There have been no hypoglycemic notifications on safety call since mid-April after the implementation. Nurses are delighted that they get the call from lab, because they can prevent their patients from harm. Valley Health nurses fully understand how to address hypoglycemia with the correct oral and/or parenteral treatments. This new process positively impacted 545 patients in a four-month timeframe.

How has the laboratory been impacted? The chemistry lab has averaged 4.5 phone calls daily in 2016, compared to 0.8 calls in 2015.

The literature on critical value versus panic, alarm, urgent, or abnormal results contains many opinions. Some researchers suggest only notifying on critical values, but others note that low serum glucose values can contribute to morbidity and mortality and need to be treated urgently (White, Campbell, & Horvath, 2014). These authors note that there is a need for consistent terminology among all laborato-ries, with a focus on patient safety and patient outcomes (White, Campbell, & Horvath, 2014). Plebani (2013) reports that there is a global disconnect regarding which lab results should be reported prompt-ly, and what these values should be, as well as what they should be called. Valley Health has decided to lead the way regarding notification of serum blood glucose values in the treatable range.

References:

Doering, T., Plapp, F., & Crawford, J. (2014). Establishing an Evidence base for critical laboratory value thresholds. American Journal of Clini-

cal Pathology, 142( ), 617-628. DOI: 10.1309/AJCPDIOFYZ4UNWEQ

Piva, E., and Plebani, M. (2013). From “panic” to “critical”” values: Which path toward harmonization? Clinical Chemistry and Laboratory

Medicine, 51(11), 2069-2071. DOI:10.1515/cclm-2013-0459

Plebani, M.(2013). Harmonization in laboratory medicine: The complete picture. Clinical Chemistry and Laboratory Medicine, 51(4), 741-751.

DOI:10.1515/cclm-2013-0075.

White, G., Campbell, C., & Horvath, A. (2014). Is this a critical, panic, alarm, urgent, or markedly abnormal result? Clinical Chemistry, 60(12),

1569-70. DOI:10.1373/clinchem.2014.227645

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Structural Empowerment

First Operating Room Fellowship

As the nursing shortage continues to put constraints on health care delivery, perioperative nurses have become one of the more difficult nursing specialties to recruit. As most nursing schools do not teach or expose nursing students to perioperative nursing, it is becoming necessary for hospitals to train staff in order to fill this important care role.

In January 2015, the Surgical Services department at Winchester Medical Center welcomed seven new nurses into a surgical nursing fellowship. This fellowship is utilizing an education course, called Peri-op 101, which was professionally developed by the Association of periOperative Registered Nurses (AORN) to guide the proper training for working in the operating room. AORN is the professional nursing organization that uses evidenced-based practice to set guidelines and standards for all perioperative professionals. The fellowship program is approximately 9 months in duration and uses a blended educational format (didactic, videos, computer modules, simulation and clinical practice) to prepare these nurses for their new role. Five of the fellows are experienced registered nurses; four transferred into the program from within Valley Health.

This unique program is educating nurses about providing surgical care, as well as providing an opportunity for nurses to learn a specialty that is not taught during nursing school. Staff members in all divisions of perioperative service areas are engaged by sharing their knowledge and expertise in various portions of the program. As reinforcement after didactic teaching, the fellows work the following day within the clinical environment practicing what they learned.

Our new perioperative nurses were so excited about the opportunity to join this unique specialty that they decided to start a blog to record their journey. The blog, charliesangelz.wordpress.com, was named in honor of their Peri-op 101 administrator, Charlie Wade, PhD, RN. We are very excited to welcome Yomi Adebayo, Sherri Armel, Julie Dellinger, Ruth Guin, Debbie Miles, Destiny Puckett, and Kimberly Zahorchak to Surgical Services at Winchester Medical Center.

Pictured (left to right): Kim Zahorchak, Julie Dellinger, Debbie Miles, Sherri Armel, Yomi Adebayo, Ruth Guin, Destiny Puckett

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2016 Nursing Excellence Award Winners

The 2016 Nursing Excellence Awards were presented at Winchester Medical Center during National Nurses Week. The process was blinded and strict criteria were followed in order to select the winners in each category below.

Excellence in Clinical Nursing – RNNominees in this category consistently demonstrate a high level of clinical competence as evidenced by an extensive knowledge base related to their clinical practice specialty, strong critical thinking skills and mastery of clinical techniques. Award winners: Lesley Watterson – Medical Telemetry; Libby Powell – AM Admissions; Laura Beard – Surgical Telemetry

Excellence in Clinical Nursing – LPNNominees in this category consistently demonstrate strong clinical skills and compassion for patients, families, peers and colleagues. They serve as role models for peers, new employees and students. Award winner: Jackie Riggleman – Nursing Float Pool

Pictured (left to right): Anne Whiteside, Laura Beard, Libby Powell, Lesley Watterson and James Sherwood

Pictured (left to right): Susan Clark, Jackie Riggleman and May Khodr

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Excellence in Patient EducationNominees in this category consistently integrate evidence-based practice and research into clinical and operational processes to meet the needs of the patient. Award winner: Katie Weber – Medical Telemetry

Excellence in PreceptingNominees in this category identify clear expectations, communicate effectively, teach new ways of achieving high quality care, value and support innovation in patient care, develop strong partnerships and promote relationships among all disciplines. Award winner: Lori Wyatt – Critical Care

Pictured (left to right): Laura Sappingfield and Katie Weber

Pictured (Left to Right): Anne Whiteside, Katrina Minter, Lori Wyatt, and James Sherwood

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Excellence in Staff EducationNominees in this category lead or participate in the development and implementation of unit-based education activities that include formal programs, clinical competencies, hospital-wide skills fairs, orientation or edu-cational materials for staff, patients and families. Award winner: Jane HiseySmith – Clinical Education

Excellence in Performance ImprovementNominees in this category develop and implement sustained programs that have a positive impact and measurable results on the nursing profession or the quality of care provided to patients, families or the community. Award winner: Joyce Dunlap – Oncology Service Line

Excellence in Mentoring/CoachingNominees in this category are instrumental in the development and growth of others. Mentors answer questions others need to succeed in reaching their goals. Award winner: Millie Fisher – Home Health (not pictured)

Excellence in Nursing ResearchNominees in this category have completed nursing research and clinical investigation within the past year that stimulates the development of new knowledge or improved patient outcomes. Award winner: James Dingess – Medical Telemetry (not pictured)

Pictured (left to right): May Khodr, Jane HiseySmith, Jane Orsie, Anne Whiteside, and James Sherwood

Pictured (left to right): Carolyn Wilson, Anne Whiteside, Joyce Dunlap and James Sherwood

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Excellence in Informatics/DocumentationNominees in this category are instrumental in implementing evidence-based practice and technology infrastructures to support patient-centered care and interprofessional integration at the point of care. They are an important resource for all front-line caregivers using the EMR on a daily basis. Award winner: Pat Baker – Critical Care (not pictured)

Excellence in Nursing LeadershipNominees in this category have made significant contributions in support of the goals of the division of nursing and the organization as a whole. Excellence in Nursing Leadership award recipients serve as role models of professional practice for their peers. They have developed or implemented operational improvements to meet the diverse needs of patients and their families. Award winner: Jennifer Riggleman – Nursing Administration

Excellence in Community InvolvementNominees in this category have made significant contributions to the organization and the community. Their contributions have had a positive impact on patients, families, nursing schools or the community at large. Award winner: Jennifer Hardware – Nurse Navigator

Pictured (left to right): Karen Peddle, Lori Brown, Sonja Sine, Jennifer Riggleman, Anne Whiteside, and James Sherwood

Pictured (left to right): Mary Ann O’Connor, Jennifer Hardware, Anne Whiteside, and James Sherwood

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Excellence in Nursing ManagementNominees in this category serve as role models of professional practice for their peers. They advocate for and participate in clinical improvement activities. Award winner: Robbie Dusing – Medical Telemetry

Excellence in Patient SafetyNominees in this category promote a culture of safety by demonstrating high reliability to our patients and consistently utilizing all safety measures available when treating their patients. Award winner: Skyler Shimp – Stepdown Unit

Pictured (left to right): Grady (Skip) Philips, Robbie Dusing, Anne Whiteside, Jennifer Riggleman, and Kammie Riggleman

Pictured (left to right): Janet Nordling, Anne Whiteside, Skyler Shimp and James Sherwood

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Nurse Education Progression Since 2014, nursing education progression has been an important strategic initiative at Winchester Medical Center and throughout Valley Health. Research and evidence suggest better patient and nurse outcomes associated with higher levels of educational attainment. The initiative is also in keeping with national efforts to promote baccalaureate in nursing for entry to practice, recognizing that the majority of health professions require graduate level entry to practice (e.g., DPT, MS-OT, PharmD, MD, MS-PA). Registered nurses continue to represent the largest workforce with the greatest potential influence on patient care.

Winchester Medical Center is currently 59% BSN or baccalaureate in nursing prepared — the same as 2015. However, an important metric of interest is that 56% of all associate degree nurses are enrolled in BSN completion programs (n=189 enrolled out of 337). This number excludes nurses who are exempt from the BSN requirement; age 55 with 10 years of nursing experience (n=54).

# <AD-N #enrolled #not enrolled #enrolling #exempt %enrolled

391 189 85 47 54 56%

Of the six Valley Health hospitals, Winchester Medical Center employs the highest percentage of baccalaureate in nursing prepared nurses. The table below compares the six Valley Health hospitals’ percent BSN for 2014-2016.

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Valley Health invests in its nurses and their education in several ways. In 2016, the following investments were made:• More than 1.2 million dollars in tuition assistance provided• 49 Jump Start BSN Awards ($1,000 each) provided to eligible nurses enrolled in a BSN completion program• $30,000 Nursing Education Textbook Reimbursement

MSN Reimbursement Report 2016

BSN Reimbursement Report 2016

ADN Reimbursement Report 2016

Number of Nurses Applied 25 Number of Nurses Applied 77 Number of Nurses Applied 14

Number of Applications 37 Number of Applications 124 Number of Applications 16

Average Amount Requested per application

$232.37 Average Amount Requested per application

$140.07 Average Amount Requested per application

$320.51

Average Amount Requested per nurse

$330.68 Average Amount Requested per nurse

$225.57 Average Amount Requested per nurse

$369.82

Largest Amount Requested $400.00 Largest Amount Requested $400.00 Largest Amount Requested $400.00

Smallest Amount Requested $58.70 Smallest Amount Requested $9.99 Smallest Amount Requested $77.00

Total Amount Spent $8,597.70 Total Amount Spent $17,369.08 Total Amount Spent $5,070.48

Just Get Started BSN Class—MTH-157 STATISTICSOne additional strategy to reduce barriers with nurse education progression was offering a “Just Get Started BSN” course in the fall of 2016. Conversations with nurses over the past three years identified the need for a tipping point for return to school. Since most universities required a prerequisite course in statistics this seemed an obvious choice for offering on-site at Winchester Medical Center. The Winchester Medical Center partnered with Lord Fairfax Community College to offer the MTH-157 Introduction to Statistics course.

Twenty-three registered nurses from Valley Health successfully completed the statistics course during the fall 2016 term. It was obvious from the nurses’ final statistics presentations that incredible learning took place. Many students utilized data from their units or nursing specialties for analysis and identified statistical significance for the hypotheses of interest. Based on positive evaluations and nurse interest, the same course was offered again during the spring 2017 term. This program has proven to be a successful partnership that benefits Valley Health, our nurses, and Lord Fairfax Community College.

Academic Support – WMCAs a not-for-profit institution, Winchester Medical Center provides a significant amount of support to the community through student education support. Education support is offered to students in a variety of ways, including observation and career exploration experiences, as well as direct clinical care rotations. In 2016, there were 125 observation experiences totaling 2,666 hours of time with a preceptor providing explanation of care and answering students’ many questions. For individual clinical rotation requests, 1,898 health professions students logged a minimum of 176,006 hours at Winchester Medical Center. The majority of these requests were for nursing.

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During the final semester of study, nursing students complete a capstone clinical rotation assigned to a nurse preceptor. In 2016, there were 213 nursing students from 12 schools of nursing receiving 24,578 hours of experiential learning support from a licensed registered nurse. See the table below for a detailed breakdown of the data.

2016 – Number of 1:1 Preceptorships (Undergraduate)

School Spring Summer Fall Total Yr Total # Hrs

Allegany College of MD 0 2 1 3 246

Blue Ridge CC 1 0 0 1 120

Denver College SON 1 0 0 1 180

ECPI 0 1 0 1 72

George Mason U 0 0 1 1 144

Indiana U 0 0 2 2 192

Lord Fairfax CC 45 6 0 51 5940

Shenadoah U – BSN 28 0 36 64 6144

James Madison U 11 0 8 19 3800

Blue Ridge Community & Tec College 14 0 6 20 2400

Hagerstown CC 17 0 12 29 1740

Shepherd 18 0 12 30 3600

TOTALS 133 6 74 313 24578

Often, the nursing student makes an employment choice following their rotation, and many have chosen to work at Winchester Medical Center after a positive experience on their assigned unit.

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Exemplary Professional Practice

Genetic Counseling

With the creation of the Oncology Genetics Program in January 2016, Winchester Medical Center is now able to offer on-site genetic counseling to patients and fami-lies at risk for a hereditary cancer syndrome. Christie Jett is a board certified genetic counselor who splits her clinical time between the Shenandoah Valley Maternal Fetal Medicine practice and the Oncology Genetics Program.

From January to November 2016, the Oncology Genetics program received 167 referrals and has seen more than 90 patients. Roughly two thirds of the referrals are related to a personal or family history of breast cancer, with the remaining one third comprised of colorectal and other cancer types. More than two thirds of the patients seen in the Oncology Genetics Clinic choose to pursue genetic testing, and of those patients around 15% receive a positive genetic testing result. For these patients, a

genetic diagnosis can change not only their medical management but also impact the care of their siblings, children, and even more distant relatives.

Working in conjunction with the Pathology department, the Oncology Genetics Program has also launched a universal screening program examining all resected colorectal tumors for Lynch syndrome. This program will help identify patients that would benefit from increased cancer screenings who may not otherwise be considered high-risk and thus would be missed by traditional referral methods. The Oncology Genetics Program has seen tremendous and exciting growth in 2016 and hopes to expand its services in 2017 to better meet the growing need for genetic counseling throughout the region.

Huddle Boards

By examining patient satisfaction data for an inpatient unit at Winchester Medical Center, the need for improved staff communication on the unit was uncovered. To address the need, the clinical manager on the unit, working with our director of quality, decided to try something called a “Huddle Board” to improve unit communication.

With the help of Lean Management, the staff on the unit learned how this type of tool could enhance the communication delivered on the unit. All unit communication (e.g., safety huddle, team opportunities and improvement initiatives) has since been focused around the huddle board. The use of the huddle board has provided the staff a way take ownership in change, embrace change, and learn from change.

The charge nurses in particular have taken great pride in their work and the successes around the huddle board. The work of the team that initiated this process improvement endeavor has served as a model for other units. Due to the team’s success in improving patient satisfaction scores with better communication, other inpatient units have taken notice and have implemented huddle boards, as well.

Christie Jett, MS, CGC Genetic Counselor

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Modifying ID Badges for Employee SafetyClinical staff at Winchester Medical Center voiced concerns about the inclusion of last names on Valley Health identification badges, and personal safety concerns related to dissatisfied patients’ ability to identify staff members personally. Substantial work was done in terms of investigating regulations regarding staff identification, the scope of the problem (who is affected and to what extent) and identifying possible solutions.

The Nursing Practice Council went on to meet with the lobbyist for the Virginia Nurses Association and learned that this concern is not unique to Valley Health; it is a global concern. The Virginia Board of Nursing (VBN) agreed that the Valley Health story was voiced by many other hospitals and was helpful in guiding nursing leadership and the Nursing Practice Council to possible solutions. Nurs-ing leadership also queried the other Virginia Magnet hospitals for their thoughts and ideas. Valley Health’s director of Quality Improvement studied the regulations regarding patient rights, and Human Resources reviewed the possible solutions. Many nurses came forward with specific examples that helped illuminate the urgency of the need.

This collective effort resulted in a change of policy at Valley Health for badge information, such that the badge format is now first name and last initial for all employees below director level.

There was consistent support from all corners of Valley Health to find a solution to this issue. Employee safety and wellbeing is an organizational imperative and was demonstrated by leadership’s recognition of the problem and the implementation of this policy. The nurses who told their personal stories did so in a very articulate and compelling manner — a hallmark of a truly professional group of clinicians.

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Delayed BathingIn 2015 Winchester Medical Center’s Mother/Baby unit instituted a delay in newborn bathing. Newborns would not receive their first bath until they were at least six hours old and had one feeding. Prior to this process change, newborns were receiving their bath once their temperature reached 98 degrees.

Clinical Nurse Joanna Reynolds, BSN, RNC-MNN completed a research study on “Bathing the Late Preterm Newborn: Minimizing Stress during Extrauterine Transition.” Joanna wanted to determine whether eliminating a source of extraneous stress for newborns of 35-37 weeks gestation might help their transition process and avoid admission to the NICU for temperature-related changes. Evidence suggested that these newborns would be at risk for hypothermia, hypoglycemia, hyperbilirubinernia, respiratory distress and sepsis workup.

Three quarters of all preterm births are late pretermers and these newborns account for approximately 10% of all births in the U.S. One third to one half of all later pretermers will require NICU admission. They have four times the chance for rehospitalization during their first year compared to term babies and three times the mortality rate of term newborns.

Often, late pretermers only exhibit signs of distress in subtle changes, occurring over a period of time, possibly over the first 24-48 hours of life. Due to late pretermers’ neurological and physiologic immaturity, caregivers must minimize external stressors. Caregivers can minimize unnecessary stressors on later pretermers by modifying their assessments and routines. They can also occupy a prime role in modeling appropriate care techniques for later pretermers and can ensure the successful transition of these babies from birth to admission to discharge. Joanna’s study included references from Journal of Clinical Nursing, Pediatrics, Journal of Obstetric, Gynecologic & Neonatal Nursing, Pediatric Nursing and Evidence-Based Practice in Nursing and Healthcare.

Upon completion of Joanna’s study she presented her findings to the Mother/Baby unit staff, including the unit’s manager and educator. The data was then shared with the unit-based Practice Council in which a determination was made to assess our current practice and make the necessary changes. Michelle Heishman, BSN, RNC-MNN, Clinical Manager, presented the research study to the Pediatric Department and requested support to change the prior bathing process for all newborns. The Pediatric Department group initially declined the request.

Michelle returned to the Pediatric Department requesting support to delay the bathing for all newborns and provided the following evidence:

GDG consensus based on existing WHO guidelines: Bathing should be delayed until after 24 hours of birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and bay should not be separated and should stay in the same room 24 hours a day.

United States Breastfeeding Committee references WHO guidelines:Evidence has shown that postponing the first feeding is a strong predictor of breastfeeding failure. In addition to increased risk of neonatal hypothermia, immediate bathing of the infant and mother may disrupt initial breast-feeding behavior. Infants appear to have a heightened sense of olfactory learning in the first hour after birth, naturally seeking their mother’s breast by smell, particularly if and amniotic fluid is present there.

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Even after the infant and mother are transported to the postpartum area the infant should stay skin-to-skin on the mother’s chest. It may take some infants longer than one hour to spontaneously initiate breastfeed-ing, particularly if the mother was given sedating medications during labor.Skin-to-skin contact in the three hours following birth is associated with improved exclusive breastfeeding rates in the hospital.

American Academy of Pediatrics Section on Breastfeeding:Normal newborn care such as weighing, measuring, bathing, needle sticks, vitamin k, and eye prophylaxis should not delay early initiation of breastfeeding.

Healthy term newborns with no evidence of respiratory compromise will be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished, unless medically contraindicated.

After the evidence was presented the approval was given to change the prior process. On March 16, 2015, the delay in newborn bathing was initiated.

Winchester Medical Center RNs Outperform the National Database for Nursing Quality Indicators (NDNQI) For RN Satisfaction in 2016

To outperform the Magnet hospitals in the database, Winchester Medical Center must outperform 51% of the time. Winchester Medical Center had 32 units par¬ticipate in the RN Satisfaction Survey in April of 2016. In order to outperform, at least 17 of 32 units needed to outperform the benchmark. Winchester Medical Center had 20 units out of 32 (63%) that outperformed the benchmark. Our goal is to not leave any unit behind, and have all 32 units outperform on the next survey.

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New Knowledge, Innovations & Improvements

Showcase for Sharing 2015

On October 23, 2015, The Nursing Research, Quality and Evidence-Based Practice Council hosted the an-nual Showcase for Sharing event at the Winchester Medical Center Conference Center. Thirty-one posters sharing evidence-based research and performance improvement projects were viewed by more than 100 attendees. A panel of 16 judges reviewed the poster presentations and selected the top three winners in both research and performance improvement.

The winners were as follows:Research1st Place “ The effect of timing of antibiotics on the outcomes of febrile neutropenia patients.”

Presenter: Judy Pennypacker, RN, BSN, OCN

2nd Place “ Peripheral intravenous securement trial.” Presenters: Sheri Miller, RN, CRNI, VA-BC; Ozlem Getz, RN, CRNI; Debbie Knippenberg, BSN, RN, CRNI, VA-BC; Mary McNamara, RN, CRN, VA-BC; Cheryl Dumont, PhD, RN, CRNI

3rd Place “ Positive impact of patient whiteboard utilization.” Presenters: Lauren Ewing, BSN, RN; Dolores Crooke, MSN, RN

Performance Improvement1st Place “ Preventing C. difficile infections in the inpatient setting through patient hand hygiene.”

Presenters: Jimmy Dingess, RN, BSN; Gretchen Himes, BSN, RN, CIC

2nd Place “ Progressive mobility implementation using lean methods.” Presenters: Jennifer Riggleman, MSN, RN, NEA, BC, ONC; Mary Anne Rickabaugh, OT, C/NDT, CLT; Sharon Isbell, MS, RN

3rd Place “ Project F.I.T. follow it through on the road to excellence.” Presenters: Angela Halliwill, RN; Kiernen Spoonster

Nursing Research, Quality and Evidence- Based Practice Council members pictured left to right: Mark Miller, Beth Herriot, Jane Orsie, Dawn Coppersmith, Autumn Williams, Ozlem Getz, JoAnn Noel, Jimmy Dingess, Lisa Dellinger and Anne Whiteside

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The Effects of Timing Antibiotics on the Outcome of Febrile Neutropenia

In 2015, clinical nurse Judy Pennypacker, BSN, RN, OCN completed a research study on “The Effects of Timing of Antibiotics on the Outcome of Febrile Neutropenia.” Institutional Review Board (IRB) approval was originally obtained in October 2005, with several extensions granted over the next 10 years. In order to provide evidence with significance, it was imperative to include as many patients as possible in the study to ensure consistent evidence. With an average of only 24 patients a year presenting with febrile neutropenia and meeting the criteria, it took an extended period of time to gather data with statistical significance. The purpose of the study was to determine the correlation between the length of time to the first dose of intra-venous antibiotic, measured as the time from arrival to the treatment center to the time of antibiotic admin-istration, and length of stay or mortality. Febrile neutropenia is considered a medical emergency, much like stroke or heart attack.

This concurrent and retrospective research study comprised 217 patients from October 2005 to September 2013. Over the course of the study, the average time to antibiotic decreased from 2.52 hours in 2005 to 1.82 hours in 2013. No correlation between time to antibiotic and length of stay or mortality was found in this study. The difference in survival based on age was statistically significant. Older patients with a mean age of 67.7 years had a lower survival rate, related simply to age when acquiring febrile neutropenia.

Other researchers have noted a decreased length of stay (LOS) related to decreased time to antibiotic, although further research is required to substantiate these findings. Winchester Medical Center continues the practice of rapid administration to provide antibiotic within two hours. Winchester Medical Center has created processes that enable it to provide more prompt care; whether it is recognized now or in popula-tions in the future, shorter time for the delivery of care constantly moves medical practices forward. Partic-ular emphasis is placed on delivering the antibiotic to the febrile neutropenic patient as quickly as possible. Older patients benefit the most from the rapid administration of the first dose of antibiotic to minimize the incidence of complications that come with age. Although the study found no correlation between LOS and the timing of the first dose of antibiotic, the standard of care is to administer the first does of antibiotic “promptly,” which typically means within one hour of arrival to the treatment center.

The Winchester Medical Center Oncology unit was unable to reduce the time of the initial dose of antibiotic to one hour, but was able to reduce its antibiotic administration time by 28% and see a small, though not statistically significant, decrease in LOS.

Oncology clinical nurses learned that to increase febrile neutropenic patients’ chance at recovery, it is extremely important that the first dose of antibiotics be administered as soon as possible after arrival to the unit because of the high immunocompromised vulnerability of the patient population. Even though the research did not demon-strate any significant findings related to the time of administration of antibiotic, the staff on the unit understands that timely treatment is important for positive outcomes, particularly for older patients.

The research information was disseminated internally through the Valley Health Interdisciplinary Showcase for Sharing (SFS) held on October 23, 2015. Showcase for Sharing is a multidisciplinary research show-case hosted by the Nursing Research, Quality and Evidence-Based Practice Council at Winchester Medical Center. The febrile neutropenia research presentation took first place in the research category.

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Efficacy of Midline Vascular Access Placed by Nurses at the Bedside

“Efficacy of Midline Vascular Access Placed by Nurses at the Bedside” was a prospective descriptive research study of current practice in a 400-bed acute care hospital conducted from 2011 through 2014. To provide the least invasive and best vascular access option for patients, the Vascular Access Team (VAT) clinical nurses were trained in 2010 to insert midline catheters at the bedside. This was a new program for Winchester Medical Center at the time, so a descriptive correlational study was designed to determine the efficacy of midlines in the acute care setting.

The study used a convenience sample of all patients who had midlines inserted by the Winchester Medical Center Vascular Access Team nurses. Patients were enrolled sequentially as it was determined that they met the criteria for a midline catheter. Institutional Review Board (IRB) approval was obtained for exempt status on February 7, 2011. Data on 345 midlines was collected over three years, and the results were ana-lyzed in 2014.

The research study results demonstrated that specially trained nurses can safely and effectively insert ul-trasound-guided midline catheters at the bedside. Patients with poor vascular access and status who have had difficulty maintaining or receiving the usual peripheral IV benefit from the insertion of the midline cathe-ter. The advantage for this population is a more stable line for infusion into peripheral circulation. The study did not demonstrate a higher risk for any of the infusate used, and the complication rate was not greater than that of other vascular access devices. It was determined that the midline catheter provides stable and safe vascular access.

Following the research study, Winchester Medical Center decided it was safe to have trained and competent vascular access nurses insert ultrasound-guided midline catheters at the bedside and to continue to offer midline catheter service to patients based on assessments and referrals from the bedside clinical nurse.

To further assist clinical nurses, the VAT developed a “Peripheral IV (PIV) Access Algorithm.” This tool gives clinical nurses very specific guidelines regarding when to attempt a PIV and when not to, how many attempts they may make at a PIV insertion, how many attempts another nurse may make, and when it is time to call the Vascular Access Team to discuss other means of intravenous access, such as the ultra-sound-guided midline. Based on the knowledge obtained through this research study, the Vascular Access Team offers ongoing education to clinical nurses on midline insertions, assessment of midline insertion needs, care of midlines and the use of the Peripheral IV (PIV) Access Algorithm.

The Vascular Access Team submitted “Evaluation of midline vascular access: A descriptive study” to Nursing2014 for publication in June 2014. It was accepted and published in October 2014. Dumont, Getz and Miller authored the article. Getz and Miller, both clinical nurses, were members of the Vascular Access Team at Winchester Medical Center.

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De-Escalation Classes

Winchester Medical Center has seen an increase in violent (verbally and physically aggressive) patients on inpatient nursing units over the last few years. Staff members have voiced concern about safety for them-selves and others in the hospital. The organization aims to maintain a safe environment by providing edu-cation and training to help staff manage aggressive patient situations before an injury takes place. A course was developed to train staff at Winchester Medical Center about proper de-escalation and safety tech-niques in order to improve staff response and knowledge pertaining to violent patient and family situations (code green). This education is not mandatory, but staff members are high encouraged to attend. A two-hour course was developed in the summer of 2015. This education was developed based on staff feedback provided through the annual education survey and on education program evaluations when asked what courses they would like to have available at our facility. Staff members requested de-escalation classes and education on how to manage aggressive patients.

The De-escalation Strategies for Crisis Situations classes were started at Winchester Medical Center in August of 2015. The objectives are as follows:1. The participant will define the term “crisis”2. The participant will discuss at least two techniques to maintain personal safety when managing an agi-

tated individual3. The participant will identify at least three behavioral cues signifying risk of aggression4. The participant will identify at least two de-escalation techniques to manage an agitated individual Risk reports are completed based on aggressive/violent patient situations when a code green is needed. The following table shows the decrease in incidents since classes started in August 2015.

Quarter

Number risk reports for violent or

aggressive patient issue (Code Green)

3rd quarter 2015- Classes started August 2015

5

4th quarter 2015 8

1st quarter 2016 15

2nd quarter 2016 4

3rd quarter 2016 4

4th quarter 2016 2

We are seeing a gradual decrease and hope to further improve as more staff are trained. To date, approx-imately 150 staff members have been trained in this two-hour class. This does not count the continued training with Crisis Prevention that we see in the Emergency Department, Behavioral Health Services, Float Pool, Security and other designated areas that have requested it. These areas have the same de-escalation training, but at a higher level due to their higher-risk patient population. With this course included, we see well in excess of 400 staff trained with de-escalation strategies each year.

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New Research Fellow PositionAt Winchester Medical Center, it was recognized by our Vice President of Nursing, Anne Whiteside, MBA, BSN, RN, NEA-BC, that effectively teaching nurses the skills required for research and performance improvement required dedicated time. With this in mind, she supported the directors in budgeting for paid time for staff nurses representing all areas of the hospital to attend the eight-hour-per-month Research, Quality and Evidence Based Practice (NRQEBP) Council meetings.

During these meetings the staff learned about research and performance improvement (PI) processes. They also learned about the use of Excel, poster-making, and the conduct of journal clubs to facilitate evaluation of the level of evidence and best practice associated with research.

This process has been in place since 2005 with varying levels of success. In 2014 the needs of the nursing research program were assessed under Anne’s leadership, in conjunction with the director of nursing research. It was determined that for staff nurses to be able to truly learn the research and PI processes they needed to have more time for one-on-one coaching and direct involvement in research.

In response to the need, the decision was made to include a 0.5 FTE in the budget for a nurse fellowship in research. Candidates for the fellowship were required to be direct care staff nurses with a BSN. The position was structured to be “half-time,” with the nurse working 20 hours per week in research and 20 hours per week in direct care on their original unit. The nurse manager of the unit would be consulted to determine if they could support the direct care nurse time away from the bedside. The strategy was to keep the identified nurse in the fellowship position for six months and then rotate another nurse into the position. This way the requisite research and PI skills could be acquired by direct care nurses who could then more easily take those skills back to their unit and assist with PI and research at the point of care.

The first nurse chosen for this position was James Dingess, BSN, RN, a clinical nurse on Winchester Medical Center’s Medical Telemetry unit.

Dingess began the role as Nurse Research Fellow in March 2015 and worked 20 hours per week in the role through August, 2015. Dingess was taught the essentials of re-search as well as the basics of using SPSS and data anal-ysis. He worked with the director of nursing research to conduct and assist others with research and PI projects.

Projects included: a patient hand hygiene project; a PI project on the medical telemetry unit aimed at decreasing noise at night; a PI project on the Oncology unit to improve the accuracy of documentation of intake and output; and a research study on alarm fatigue in the ICU. James Dingess became known to the other staff nurses as the person to go to for help with research and PI projects.

The Nurse Research Fellowship position continues with another clinical nurse, Tom Padrutt, BSN, RN, from Winchester Medical Center’s Pulmonary/Renal unit.

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The 3rd Annual Valley Health Interdisciplinary Research and EBP Conference

The 3rd Annual Interdisciplinary Research and Evidence Based Practice Conference was held on February 12, 2016 in the Winchester Medical Center Conference Center. The event featured eight speakers; four nurses and four physicians.

The participants were presented with information about research projects ranging from cardiac blockages and stents to new procedures in valve replacement. They also learned about performance improvement projects focused on advance directive initiatives and efforts to decrease C. difficile infection rates by in-creasing patient hand-washing before meals.

The keynote speaker was Vineet Chopra, MD, from Michigan Health Systems. Dr. Chopra’s presentation, “Choosing the Right Vascular Access Device: Does Science Meet Practice?” had the attention of the entire room. In addition to the presentations, participants scored six poster presentations from Valley Health staff during breaks. The three winning posters were:

First Place – “¡Tengo Leche! Building Upon a Successful Initiative to Increase Breastfeeding Rates among Rural Hispanic Immigrant Mothers.”

Second Place – “The Effects of Timing of Antibiotics on the Outcome of Febrile Neutropenia.”

Third Place – “Assuring Accurate Intake and Output

Cheryl Dumont, Oz Getz, JoAnn Noel, Vineet Chopra, MD, Lisa Dellinger and Jane Orsie.

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American Sign Language InterpretersValley Health now has 24/7 access to American Sign Language (ASL) interpreters at all points of access, in all facilities, via video remote interpreting devices (VRI) for our deaf patients or deaf family members. Using this technology, an interpreter is visible to the patient on an iPad screen and the patient is visible to the interpreter, allowing for two-way visual communication.

This is a tremendous step forward in patient safety. The VRI option is used to begin treatment immediately while an in-person interpreter is contacted. If the patient is comfort-able using the VRI device exclusively, this course of action can be taken.

This device is also a resource for more than 200 spoken languages, providing an audio-only interpreter for the less commonly accessed languages, and a visual interpreter for the more commonly accessed ones. The iPad is mounted to a mobile stand to allow it to easily move from location to location with the patient.

NICU Volunteer Baby “Cuddler” ProgramThe “Cuddler” Program, a new volunteer program, was conceived in the summer of 2014 with discussion between the Winchester Medical Center NICU staff and the Volunteer Services department. The team researched model programs and best practices in other health facilities, developed and established polices for the new program and began the volunteer recruitment.

Volunteer Applicants were carefully screened and interviewed by the teams. Once an applicant complet-ed an interview, training, criminal background screening and health clearance, NICU-specific training took place. The first volunteer NICU baby cuddler began in April 2015.

Role of the Baby “Cuddler” VolunteerThe NICU Volunteer Baby Cuddler Program was developed as a way to meet some of the basic needs of NICU infants. The volunteers, or cuddlers, provide human contact, rhythmic movements, caressing, responsiveness to babies’ movements and eye contact. The cuddler’s breathing and heartbeat are positive for the baby. A loving cuddler helps a baby develop trust, a feeling of control over their self and their environment, basic biorhythms essential for control of internal processes such as sleep-wake patterns, body movements and even the movement of food through the body. A cuddler can also help a baby relax to improve digestion, growth and responsiveness.

Twenty active volunteers give full support to the unit. The volunteers are available for three shifts Monday–Sunday. Eight more volunteers are completing the volunteer placement process and will be back-up vol-unteers to fill in and expand the operation hours. The “Baby Cuddler” volunteer is now the most requested assignment through Winchester Medical Center’s Volunteer Services department.