Background: 30 million Americans have diabetes, with an additional 84 million suffering from pre-diabetes. These patients demonstrate a significantly increased risk for heart disease, stroke, renal failure, blindness, and impaired peripheral circulation and neuropathy (CDC.gov, 2019). In the ongoing effort to improve health outcomes while reducing inefficiencies in ambulatory care, this organization has developed a diabetes health professional program (DHPP) to standardize the mechanism for providing patients with the education necessary to prevent progression of the consequences of diabetes without increasing staffing cost.

Methods: The American Association of Diabetes Educators (AADE) offers an online, self-paced diabetes paraprofessional program that provides an advanced body of core knowledge and skills related to diabetes education and management that is geared towards health care professionals. This program was utilized as a basis for the DHPP in this organization. Clinical staff (MAs and LPNs) were nominated by managers to enroll in the program. Care was taken to ensure that nominations were spread across many of the ambulatory care offices to ensure a standardized approach to diabetic education for patients and families across the organization. The DHPP is run by a registered nurse (RN) clinical educator who oversees the students, providing additional mentoring and tutoring as needed as the students learn the material. Once the students complete the program, their successes are celebrated and they immediately begin their work. They choose a taskforce (2019 taskforces include eye exam; foot care; importance of hemoglobin A1C (HA1C); importance of micro-albumin testing; and monitoring blood pressure, nutrition and blood sugars) and work together to develop educational materials and forums for their co-workers, patients, and family members. Materials may include huddle talking points, flyers and bulletin boards for the offices, pamphlets, and short videos for staff and/or patients, etc. The RN clinical educator remains a mentor and works with a dyad physician champion partner; together they provide guidance and final approval on all teaching points, materials, and forums.

Results/outcomes: The major metric for this program is the organizational diabetes bundle compliance score. YTD the score is above target at 78.22 (up from 2018 close of 77.33). Additionally, this program is designed to positively impact employee engagement and patient experience.

Implications for practice: The developed curriculum incorporates chart prep, patient communications, rooming practices, and office staff communications to provide standardized education across ambulatory care setting. This DHPP drives quality outcomes, fosters a positive environment that promotes engagement and professional development among staff, and empowers patients living with diabetes the knowledge required to achieve optimal health outcomes. The cost of the program is about $200 and is covered by many organizations’ continuing education benefit. On average, the program takes two about months to complete with a majority of the work being completed by the students at home.

Reference
1. CDC.gov. (2019). Division of diabetes translation at a glance. Retrieved from https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm

Pneumococcal disease is a leading cause of vaccine-preventable illness and death”.1 Pneumococcal vaccines are recommended for patients age 65 and over and high-risk patients, however adherence rates remain low.1 Two pneumococcal vaccines are available for older adults: Pneumococcal conjugate vaccine for adults 65 and older (PCV13/prevnar 13) and pneumococcal polysaccharide vaccine (PPSV23/pneumovax 23).

The nurses at adult primary care, a primary care clinic serving the underinsured, uninsured, and most vulnerable population of Hartford, CT, and surrounding areas, in line with the CDC Healthy People 2020 National Immunization Goals 2 saw the need to increase vaccinations in the ambulatory care setting for patients who were identified with a COPD diagnosis. Approximately 200 patients were identified and placed into four categories: patients with no history of pneumococcal vaccinations, patients who have received/not received PPSV23, patients who have not received PCV13, and patients who have received both PPSV23 and PCV13.

This nurse-driven initiative involved members of the whole team, including medical assistants who called eligible patients that were identified to come to the office for vaccinations during established pneumonia vaccination clinics. Nurses also proactively reviewed provider schedules for patients aged 65 and older who needed PCV13 vaccination. A best practice advisory (BPA) was established in the electronic medical records (EMR) with the support from the Hartford HealthCare (HHC) system support office to alert providers of the patients’ need for the pneumococcal vaccine. Vaccination rates for the population in this pilot increased as a result of this initiative: pneumovax 23 vaccination increased to 89% and prevnar 13 vaccination increased to 77%. In conclusion, the BPA has increased providers awareness to patients’ need for vaccinations in general. Once the BPA proved effective, HHC began using the BPA system wide to increase vaccinations rates. We have also seen an increase in vaccinations rates for TDap, hepatitis A, hepatitis B and influenza.

References
1. Pennant, K, Costa,J, Fuhlbrigge,A, Sax, P, Szent-Gyorgyi, L, Coblyn, J Desai,S. Improving Influenza and Pneumococcal Vaccination Rates in Ambulatory Specialty Practices. Open Forum Infectious Diseases 2015;1-9.
2. CDC. Healthy People 2020 National Immunization Goals.

Background: In response to the COVID-19 pandemic, our ambulatory care services division (ASD) primary care practices temporarily stopped in office care and adopted virtual visits. The transition to a virtual care model affected the ASD anticoagulation clinics located in the practices. Over 5000 patients needed continued anticoagulation services and monitoring. Approximately 60% of the patients required face-to-face visits.

Objective: The objective was to develop and implement a temporary solution to continue point-of-care testing and encourage patients who were able to adopt remote testing. The team’s top priorities were patient safety and comfort and nurse well-being and confidence, ultimately decreasing fear by providing care that is safe and efficient. ASD anticoagulation leaders needed a solution that would allow the team to continue point-of-care testing, maintain staff safety, and encourage fearful patients to continue international normalized ratio (INR) testing.

Methods: To ensure continuity of care for patients whose care required face-to-face visits, the team stood up seven centralized drive through tent locations and expanded home-testing capabilities. To deliver care in this new model the team took the following steps:
1. Encouraged patients who could enroll in home testing to do so and collaborated with a home-testing company to increase efficiency of enrolling new home-testing patients.
2. Utilized RNs not engaged in care at testing sites to enhance the anticoagulation services virtual team.
3. Established tent testing locations:
• Leadership assigned staff to dedicated tent teams for the duration of the project.
• RNs at tent sites donned proper PPE in accordance with Centers for Disease Control guidelines and our organization’s policy while working at tent sites.
• Tent site teams instructed patients to stay in their vehicles and wear a mask through the entirety of the visit.
• Patients were arrived in the electronic medical record (EMR) for their visits.
• While the patient remained in their vehicle the tent site RNs conducted a COVID-19 screening and completed an anticoagulation assessment.
• Virtually the team completed the visit in the EMR and managed the patient’s dosing.

Results: Warfarin management was successful; enrolled patients’ average time in therapeutic range (TTR) remain unchanged from pre COVID-19 averages. Prior to clinics closing in March 2020, the average TTR was 60.75%. In April and May 2020, the average TTR was 61%. In addition to maintaining TTR performance, the new workflows decreased appointment length of time from 20 minutes to less than 5 minutes. Shorter appointments reduced risk of exposure for patients and the nurses. Home testing also expanded; over 100 patients were transitioned to home testing. Lastly, the new process maintained staff safety; there were no reported cases of RNs exposed or diagnosed with COVD-19.

Conclusion: Our nurses skillfully collaborated to ensure safe, effective, and efficient care. Anticoagulation services temporarily closed 32 clinics for 8 weeks, quickly implementing innovative solutions to continue care for patients who could not receive care virtually. Patients continued to have their POC testing and warfarin therapy monitored, resulting in very little variation in TTR.

This poster serves as complementary material to the rapid fire presentation “Responding to COVID-19: Multidisciplinary Leadership Creating New Care Models in the Face of a Pandemic” presented during session 213 of the 2021 AAACN Annual Conference.

The rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has impacted health care systems across the United States. Emergency departments (ED), intensive care units, hospital wards, and outpatient clinics have seen an unrelenting increase in patient care volumes due COVID-19. Many other factors of this new virus compound the impact of increased volumes including viral spread, safety, personal protective equipment (PPE), and the unknown. This led to a burgeoning need to transform the way we delivered care to patients who were either presenting to the ED with COVID symptoms, identified by serology testing as being COVID (+) and/or calling the health care system.

Under the guidance of the Centers for Disease Control and Prevention guidelines and internal infections disease physicians and nurses, a system-wide response was developed to manage COVID (+) patients safely, effectively, and efficiently while containing the spread of the virus to health care workers. A resource team was gathered, working collaboratively to respond to the need to ultimately provide safe care for our COVID (+) population. The team included an operational support staff, physician, clinical nurse, advance practice leader, and the ambulatory care educator and utilized the A3 methodology for improvement. The group focused on managing patients via outpatient methods to minimize unnecessary contact with health care workers and the general population as well as decrease ED visits.

Two separate care delivery models were created, one virtual and one for in-person encounters. Within the delivery model, key components included staff needed and skill set, training/education, technology requirements, patient access to the care system, care delivery process, personal protective equipment (PPE), and safety. Re-purposing physical space and workflow onsite to minimize COVID transmission was paramount, as well as requiring the virtual team to have a designated workspace with the requisite technology. A dedicated team of redeployed clinical staff worked were precepted in person and/or virtually. Infectious disease training and donning and doffing of PPE was provided by the ambulatory care educator and the infectious disease physician in person and also via on-line and virtual formats.

Analysis of the care delivery system included reconciling data from the scheduling platform and the organization’s data warehouse management reports to determine the number of calls, messages, patients, and number of encounters. A daily dashboard was provided that displayed the total numbers of patients that received care in person or virtually.

From March 27, 2020, and April 3, 2020, through June 15, 2020, the nascent virtual outpatient management clinic (VOMC) and the newly created onsite outpatient acute respiratory clinic (ARC) managed 6,215 calls/encounters and 604 outpatient visits, respectively.

Through multidisciplinary leadership, clinical innovation, and use of the best available evidence, the team created best practices for the transformation of the care delivery and management of primary care patients who were battling COVID-19. The approaches described can provide best practices for leaders in response to newly identified infectious disease and the care delivery models.

Purpose: The aim of this quality improvement project was to increase the knowledge base and self-efficacy of ambulatory care registered nurses (RN) around diabetes education.

Background/significance: Diabetes mellitus (DM) is a preventable disease that increases the risk for serious complications, increases the risk of death by 50%, and requires chronic management. Many studies have shown that nurses do not possess adequate knowledge about diabetes to lead patient education effectively. Knowledge deficits are greatest in the areas of medications, insulin treatment, blood glucose monitoring, dietary recommendations, symptoms, and complications. Inadequate patient self-management could be improved if nurses received more in-depth training to increase their basic foundational knowledge.

Methods: Participants were recruited through convenience and snowball sampling from several ambulatory care clinics of a large academic medical center. The intervention consisted of four modules focused on DM self-management education which included pathophysiology, symptom management, and blood glucose monitoring; medications and treatment; complications, diet and health care; and patient teaching and motivational interviewing. A validated tool, adapted from 4 validated instruments from previous studies (diabetes self-report tool, diabetes knowledge tool, diabetes survival knowledge test, and diabetes knowledge questionnaire), was used to assess actual and perceived knowledge of diabetes management before and after each module.

Assessments were completed in REDCap, and IBM SPSS version 24 was used for statistical analysis. Paired t-tests were performed to analyze scores before and after the intervention. Partial eta squared values were calculated to determine effect size and statistical significance was set at p = 0.05. Descriptive statistics were used for the demographic survey and program evaluation.

Results: There were about 16 participants in the program, and more than half have been nurses for ten years or less. Post-education scores for module 1 and 2 were statistically significant (p ˂ 0.001), and the effect sizes were large at 65% and 45%, respectively. Modules 3 and 4 were not statistically significant. Aggregate data for modules 1-3, n=45, resulted in statistical significance (p ˂ 0.001). Aggregate effect size was large at 31%. Close to 60% of participants found this educational intervention very helpful, with 55% stating that they are very comfortable leading diabetes care and education as a result of program participation.

Conclusions and implications: A significant finding is that despite a fully virtual platform, this educational intervention was effective in increasing nurse knowledge related to diabetes. Continuing to promote the virtual platform for education as well as incorporating role playing and recording options into future programs will be important in engaging nurses in a way that is helpful to their practice and provides the flexibility necessary within the unpredictable ambulatory care environment. More than a third of our population has pre-diabetes, and our findings suggest that educational interventions are necessary, welcomed, and effective in providing outpatient nurses with the knowledge necessary to lead diabetes and prediabetes care and education. Nurses are well-positioned to support the shift in care to population health management, help prevent or delay type 2 diabetes, and promote overall wellness with a focus on quality outcomes.

The National Institute for Occupational Safety and Health (NIOSH) estimates that 8 million health care workers who handle or administer hazardous drugs (HDs) may be exposed in the workplace. Exposure to HDs can cause short-term or long-term side effects including skin disorders, infertility, and/or cancer. Although guidelines on handling and administering HDs have been published, there were previously no enforceable standards. USP General Chapter Hazardous Drugs – Handling in Healthcare Settings specifies practice and quality standards to promote patient and employee safety, as well as environmental protections. USP , which was initially published in 2014 and finalized in 2016, was set to be enforceable on December 1, 2019, by The Joint Commission® and state pharmacy boards. However, it has been delayed as the process of HD compounding is still being finalized. Once this has been finalized, USP will be enforceable. In the interim, health care organizations can choose to adopt USP standards, which has been encouraged by USP® to ensure safe work practices.

Non-oncology ambulatory care environments will need to make significant practice changes to be in compliance with USP . New workflows and practices need to be developed including wearing personal protection equipment (PPE), using a closed-system transfer device and safely cleaning up a spill. Although the oncology environments will also be impacted, the standards are not new as they are based, at least partly, on the Oncology Nursing Society guidelines. Therefore, in these environments, practice changes have already started to take place.

The objective of this poster is to describe how non-oncology ambulatory care environments can prepare for USP . The first step in being successful will be to create an interdisciplinary team with oncology, inpatient, occupational health, and pharmacy. Partnering with these disciplines allows for individual expertise to inform how to safely implement USP . The second step will be development of an educational plan for clinical staff (RNs, LPNs, MD/APPs) administering and cleaning HD spills. In addition, an educational plan will need to be developed for ambulatory care leadership to guide them on the supplies they will need (e.g., PPE, HD waste containers, spill kits, etc.), as well as the operational workflows to ensure employee and patient safety. The final step in successfully preparing for USP in the non-oncology ambulatory care environments will be to develop resources to support the implementation of the program (e.g., skill validations, online learning tools, etc.).

At our academic institution, the ambulatory care environment includes over 50 non-oncology ambulatory care clinics, comprising of approximately 150 clinical staff administering HDs. Preparing to implement USP standards will require substantial change in the non-oncology ambulatory care environments. In order to be successful, it will require working as an interdisciplinary team to develop educational plans, implementing safe work practices, and developing resources to support clinical staff and ambulatory care leadership to comply with USP standards.

Problem/purpose: To promote consistent clinical orientation experiences and clinical practice in a complex health care system with two separate human resource departments and diverse practice settings.

Design: Partnership among nursing professional development practitioners, ambulatory care services leadership and human resources departments to provide an integrated clinical orientation for new and transferring staff members.

Setting: Ambulatory care services at an academic health system in the southeast

Participants/target audience: New hires and transfer employees starting at the organization’s hospital-based clinics and the physician practice clinics.

Methodology: In order to provide consistency of orientation information and documentation as well as consistent care across practice locations, discussions were held with key stakeholders in both organizations under the broader health system. While not all aspects of orientation could be combined due to separate HR departments and benefit structures, the clinical components and leadership presentations were combined to provide a consistent message and vision to new and transferring employees. Logistical challenges included where to hold orientation sessions, parking for off-campus orientees, essential orientation elements for new hires at greater geographic distances, creating one set of policies for all ambulatory care locations, and creating specialty-specific “competency-based orientation” (CBO) documents instead of clinic-specific CBOs.

Results/outcomes: After partnering with the key stakeholders and collaborating to meet essential integration components, the combined orientation began in February 2018. In the following 12 months, approximately 350 new hires and transfer employees have attended the integrated ambulatory care orientation. This has provided a format for all ambulatory care employees to meet with executive leadership within ambulatory care services and to receive consistent communication on patient care goals and strategic vision, in addition to making a personal connection between leaders and new clinical staff. All RNs, LPNs, and medical assistants are also provided with information on clinical resources and complete a medication knowledge assessment utilizing these online resources. In addition, clinical staff complete learning modules and in-seat education on the electronic medical record, as well as participating in a class to complete their level I CBO (level II and level III are completed in their clinics). Most recently, an ambulatory care skills lab has been added to orientation, which includes a dosage calculation test, medication administration review and skills demonstration, EKG lead placement, and an emergency response drill (first five minutes of a code). Results have been positive from both orientees and leaders and documentation of the orientation elements has improved.

Implications for future practice: With increased health care system expansions, other organizations may benefit from a similar approach to integrating orientation for a consistent experience and standardized practice and documentation.

Purpose: A HRSA grant targeting the integration of primary care content into a BSN pre-licensure program led to the creation of a new academic-practice partnership with a federally qualified health center (FQHC). Senior level students completed clinical learning experiences in primary care clinics of the FQHC. Clinical placement in the primary care setting is a relatively new learning environment for BSN students. Therefore, nurses now functioning as preceptors, have not recently received professional development related to the knowledge and skills of precepting. A learning needs assessment revealed that although preceptors indicated basic knowledge, they also had a desire to learn more related to current strategies for appropriate oversight and clinical teaching of BSN students.

The purpose of this poster is to share the novel aspects of design, delivery, and evaluation of a pilot preceptor education series for a new academic-practice partnership, while incorporating a preceptor learning needs self-assessment.

Description: Nurse managers identified a lack of recent experience with RN student learning and formal preceptor development opportunities. While potential learning needs were discussed at that time, a self-assessment was constructed and completed by potential preceptors. Education topics were derived from the self-assessment, core preceptor competencies, and educator expertise.

Evidence-based content was delivered in 30-minute sessions scheduled at the beginning of the RN work day.

A virtual delivery format allowed individual preceptors from various practice or academic locations to join in group discussions which would not have been possible in face-to-face training.

Clinical faculty, site managers (RNs) and potential RN preceptors attended an initial one-hour session focused on the new academic-practice partnership and orientation to academic course requirements. A facility specific preceptor handbook was distributed to support the session content and included preceptor expectations, student evaluation templates, and tips for precepting in the primary care setting.

The educational series was designed building from simple supportive teaching strategies to complex, evaluative, and accountability strategies. Each session can be completed independently but builds upon the previous module’s content. Sessions included precepting processes, reflection on past experience, and analysis for future application. Continuing education credit was awarded for individual sessions as live or recorded events.

Evaluation/outcome: Session outcomes were assessed through group discussions and individual evaluations revealing new insights about application of the topics to the primary care setting. Examples include allowing students to determine learning goals while working in a drive-up clinic setting, encouraging students to take a leadership role when designing a flu clinic, and engaging students through provision of formative evaluation. Participants also discussed applying their new knowledge in other interprofessional relationships within the practice setting. A collective evaluation score of 4.66 (of 5-point scale) indicated that participants found the session content and presenters to be effective in achieving session outcomes.

The series will be evaluated using grant-required evaluation questions, general applicability of the content to practice, and usefulness of the novel delivery approach. Attendance ranged from 40-60%; however, the model accommodated independent learning so additional preceptors and RN staff can benefit from the professional development opportunities.

Purpose: Many challenges arise when considering emergency response in an ambulatory care setting. After thoughtful assessment of an organization’s 30 practice sites in eastern Massachusetts, it was recognized that change was necessary to be more in line with ambulatory care evidence-based practice and ambulatory care professional association recommendations. Research indicates that patients who received basic life support (BLS) in a pre-hospital setting have higher survival rates and lower mortality rates than those who received advanced cardiac life support (ACLS) (Ann Internal Medicine, 2015; JAMA Intern Med, 2015).

Description: Management of medical emergencies at the multi-practice ambulatory care center included ACLS response with the use of code cart equipment and medications. Acknowledging the varying frequency in which emergencies that required this level of response occurred confirmed that change was necessary. When ACLS skills are infrequently used in practice, comfort and competence levels are low. Review of safety event reports revealed that common medical emergencies seen throughout the organization included minor medical events such as fainting, nausea, falls, seizures, and bleeding. The medical emergency response model shifted to focus on BLS, including first aid, automated external defibrillation (AED), and activation of emergency medical services (EMS) when needed.

This change required buy-in from key stakeholders including operational and clinical leaders, physicians, advanced practice clinicians, nurses, and other direct care employees. Policies were revised to anchor on the new model. The initial steps included the purchase and installation of 120 AEDs, with onsite training and requiring all direct patient care employees to receive American Heart Association (AHA) BLS certification, and additional training on handling other common medical emergencies. In order to replace code carts in most areas of care, 188 rapid response (RR) bags were deployed across the practice sites. The RR bags include supplies and medications to manage minor medical emergencies and initiate BLS. Due to the acuity of care provided by procedural and some specialty areas; certain departments, including urgent care, cardiac testing, endoscopy, and the special procedures unit will retain code carts and will be certified to provide an ACLS response. Using a standardized template that anchors on principles outlined in the policy, RR plans will be developed and implemented on a local site level.

Ongoing training is critical to ensure the knowledge and skills to recognize early signs and symptoms of a decompensating patient and manage minor medical emergencies are present. Mock events, which will be informed by common themes reviewed through the safety reporting system, will engage staff and allow for practice and further development of these essential skills.

Evaluation/outcome: Creating safe response to medical emergencies with the development of RR in a multi-location ambulatory care center requires a great deal of ongoing assessment and review. Measurable outcomes include posting local site plans centrally on the organization’s intranet after development and increasing staff preparedness and confidence to handle an event with the use of the RR bag. Feedback from staff on this model will be reviewed after every mock event. Safety events will be tracked to ensure appropriate response to a patient event.

Primary care focuses on maintenance of health and management of chronic conditions. According to the Georgia Department of Public Health (GDPH), the Centers for Disease Control (CDC) and the American Diabetes Association (ADA), approximately 14.2% of the adult population have been diagnosed with diabetes mellitus (DM), and an additional 36.1% of the adult population have prediabetes. Diabetes mellitus is a leading cause of morbidity and mortality and requires consistent monitoring and treatment to minimize complications. COVID-19 has disrupted the consistent delivery of care for patients with DM and hence potentially placing them at risk for worsening disease management.

A large academic medical center in Georgia month to month monitors A1C metrics in relation to care of the person who has DM. The metrics include both an A1C greater than nine and missing A1C value. Review of data revealed an increase in both metrics beginning in March 2020 and trending upward through September 2020. An interdisciplinary group in primary care consisting of registered nurses, medical assistants, administrators, and providers reviewed the trending data in correlation with clinic closures and decreased access to primary care. The data revealed a 3% increase in the number of missing A1Cs and a 4% increase of the number of patients with an A1C greater than nine. The team wanted to understand the progressive increases. The team created a standard process to directly outreach/education to patients with diabetes, understand barriers and address the need for an A1C in accordance with the ADA standards of medical care in diabetes (2020).

The quality improvement project used A3 methodology and PDSA to create, implement, and review a standard process for direct patient outreach/education. The project included multiple components around data collection and review: access of data, identification of clinic and provider, understanding of metrics/data, review for duplication, antidotal barrier comments from patients, and a mechanism for tracking the information. Additionally, a foundational process was created which included identification of staff for outreach/education, process for outreach/education, communication scripting, scheduling patients for lab and provider visits, and follow-up. Patients who were missing an A1C received direct outreach/education from the clinical staff to include phone calls using scripted communication and education.

Over a period of two months, 1385 patients were identified as missing an A1C. Of these patients, 100% received direct outreach/education from the clinical staff, 990 provider appointments were scheduled with an A1C obtained decreasing the number of patients with a missing A1C from 1385 to 395. Anecdotal feedback from patients identified fear and lack of urgency in getting the A1C completed in the clinic. Additionally, patients expressed appreciation for the phone calls and education. As COVID-19 continues the quality improvement project will subsist to understand barriers for patients and how clinical staff can provide the support, education and access needed to care for patients with DM.