Post-AMI Discharge Follow-Up Strategies and the Impact on Readmission Rate: Experience from the ACC Patient Navigator Program

Identification: P03

Background: As part of the American College of Cardiology (ACC) patient navigator program (PNP) phase II focus MI, we continued risk-specific interventions implemented in phase I to reduce AMI readmissions. Concentration was placed on identifying strategies most impactful on increasing early post-discharge follow-up as it has been promoted as a method of reducing 30-day readmission rates.2

Methods: A multidisciplinary approach was implemented to include the cardiologist, transition nurse, inpatient pharmacist, patient navigator, and the ambulatory care clinic nurse. Special needs were identified during discussions at the team’s daily multidisciplinary rounds. AMI patients received disease-specific education by the transition nurse and pharmacist prior to discharge. The patient navigator scheduled a 7-day follow-up appointment with a cardiology or outside provider based on the patient’s individualized needs prior to discharge. Follow-up phone calls were made 72 hours post-discharge by the transition nurse, and, at a minimum, 30- and 90-day calls were made by the ambulatory care clinic nurse. Each call was structured to solicit specific information regarding cardiac specific medications and symptom management and encourage follow-up appointment compliance and cardiac rehab participation.

Results: Data was collected January 2018 through September 2019. A total of 135 AMI patients were included in the National Cardiovascular Data Registry (NCDR®) Chest Pain-MI Registry™. 60% completed at least one appointment within 30 days post- discharge and 32% completed an appointment within 7 days. Follow-up calls were made within 72 hours; however, very few patients answered the call. requiring a message to be left with the nurse call-back information and appointment details. A total of 15 patients (11%) readmitted within 30 days, with 8 not having a follow-up call or completed appointment. Follow-up calls at 30-days post-discharge averaged a 77% success rate, and 90-day calls averaged 65%. A total of 16 patients (12%) readmitted within 90 days, with 8 not receiving a 30-day follow-up call. Those readmitted had one or more high risk factors including insurance limitations or unfunded status; discharge to assisted living; special caregiver requirements; active transplant evaluation; or having multiple co-morbidities, including cancer, which effected their compliance with cardiology follow-up.

Conclusions: The data reveals that in addition to inpatient interventions, telephonic nurse outreach, and early follow-up can help to reduce readmissions. Increased patient compliance with follow-up was noted in one large internal medicine practice with dedicated ambulatory care nursing staff to conduct post-hospitalization follow-up calls and ensuring a visit was completed within 7-14 days post-discharge.

References
1. Pandey A, Golwala H, Hall HM, et al. Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction. Findings from the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry–Get with the Guidelines. JAMA Cardiol. 2017;2(7):723–731. doi:10.1001/jamacardio.2017.1143
2. Tung YC, Chang GM, Chang HY, Yu TH. Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure. PLoS One. 2017;12(1):e0170061. Published 2017 Jan 27. doi:10.1371/journal.pone.0170061

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Improving Transgender/Gender Non-Binary Knowledge and Self-Efficacy in an Outpatient Clinic

Identification: P10

Transgender/gender non-binary (TGNB) individuals experience health disparities such as gaps in knowledge amongst providers and health care organizations.

To understand the level of knowledge and self-efficacy at an organizational level when providing health care related services to the TGNB population within Eastern Riverside County, an evidence-based practice (EBP) project was created using Brown and Ecoff’s EBP Institute Model. The study was a prospective cohort study that recruited a sample of 150 employees and community partners to participate in a two-hour TGNB intervention. The participants that were recruited consisted of various socio-demographic such as age, sex, sexual orientation, and gender identity backgrounds.

The data was collected using a pre-test and post-test instrument that captured information assessing the overall knowledge and level of self-efficacy of the individuals participating in the intervention. Questions consisted of: 1) how confident are you with working with the transgender/gender non-binary community, 2) how confident are you in applying your knowledge into your daily practice? Rate your knowledge in best-practices when working with the transgender community.

Data was analyzed using SPSS version 25, and responses were compared using a non-parametric Wilcox-Sign Ranks Test. Based on the findings, there is an increase in knowledge and self-efficacy after the intervention was conducted. When comparing the results on “how knowledgeable are you of the transgender community,” 28% responded very little knowledge for the pre-test while 63% responded knowledgeable/very knowledgeable on the post-test. When comparing “how confident are you working with the TGNB community,” 46% responded that they had very little confidence/somewhat confident on the pre-test, whereas 83% responded confident/very confident on the post-test. In addition, questions such as “please rate your knowledge of the transgender community, please rate your knowledge of the gender non-binary community, best practices involving the transgender community, confidence in working with the TGNB community, and confidence in applying your knowledge into your daily practice” illustrated normal distribution with (P=0.02) making the intervention significant.

As a result of the intervention and the preparation leading up to it, it was identified that the employees and community partners in attendance were receptive in more education towards culturally competent care for TGNB individuals. In addition, a shift in knowledge and self-efficacy can have a positive impact in patient care delivery at all levels of the organization. Based on the findings, the organization will implement a condensed 30-minute presentation from a subject matter expert that will cover best practices when working with the TGNB patients and/or community. Furthermore, the data that was collected will be utilized to develop and/or update future organizational health policies, program development, and additional resources needed to better improve care delivery. Overall, the findings from the intervention were beneficial and similar interventions could be applied for continuous development of trainings to address health disparities in other marginalized communities. 

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Nurse-Driven Pneumonia Vaccination Initiative in Adult Primary Care

Identification: P18

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.

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Anticoagulation COVID Response

Identification: P19

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.

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Nuggets of Knowledge for the Novice Preceptor in Primary Care: Piloting a Novel Delivery Approach

Identification: P27

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.

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Medical Assistant Vaccine Administration

Identification: P34

Introduction: In 2017, Massachusetts Department of Public Health (DPH) sent a circular to all clinician practices approving medical assistants (MA) to administer vaccines. This approval for MAs to legally administer vaccines was new for the state of Massachusetts. Our large ambulatory care center with inconsistent practice expectations met this change by standardizing practices and successfully creating a comprehensive plan of qualifying, validating, training, and empowering their medical assistants to function at the top of their scope of practice.

Background: The DPH circular provided criteria regarding the recommended guidelines for education, experience, and training which allowed medical assistants to administer vaccines and the provision of supervision to adhere to in order to justify this practice. The multi-specialty ambulatory care center was comprised of several smaller and larger primary care practices acquired at various times to become one large entity. Prior to the application of this project, practices among the various sites ranged from some sites allowing MAs to administer vaccines, while other sites that did not.

Objective: The updated state guideline would ensure that patients would have easy access to vaccinations and that only select qualified medical assistants with validated vaccine training and skills could administer vaccines. The goal was to empower and train the current medical assistant workforce to safely administer vaccines while allowing them to practice to their full scope. Additional sub-goals included retention of staff and employee satisfaction.

Methods: Extensive collaboration and employee records documentation was required to ensure compliance with law and standardization. The plan was to integrate this practice not only with the current staff, but also in onboarding new MAs. Key stakeholders included legal, human resources (HR), safety, infection control, and practice leaders/administrators. This project required top leadership buy-in at all levels!

The project was implemented in four steps:
1) Identify MAs who qualify per state regulation to safely administer vaccines: implemented through legally vetted attestation forms, and processes which identified the MAs into two state approved categories.
2) Train the identified MA’s to administer vaccines: implemented by creating a comprehensive vaccine curriculum which included web-based online learning platform, in-person class, simulation of vaccine skills, and vaccine administration documentation. Curriculum included safe medication administration, handling and storage, adverse reaction identification, and recognizing and reporting unsafe practices.
3) Trained MAs required nurse validation of vaccine skills in supervised settings: implemented by requiring nurses to supervise and validate ten vaccine administrations during flu visits prior to MAs administering vaccines on their own.
4) Document successful candidates in centralized HR records: on completion, the manager/supervisor sends the names of successful candidates to be stored in the centralized HR system.

Outcome: By 11/05/2020, 30 MAs completed all the requirements, and another 24 have been scheduled for training. New processes were put in place including, a new job title, new list in HR for MAs eligible to administer vaccines, and new ID badges. They supported staffing by reducing workload on nurses. Supervisory requirements met at each site to keep patients safe, and MAs empowered with practice change.

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Leveraging Technology Solutions to Automate Informed Consent for Outpatients

Identification: P35

Problem: Paper-informed consent forms are associated with incomplete and or inaccurate information such as missing signatures and incorrect patient identification. The Food and Drug Administration’s bioresearch monitoring program audit for the 2019 fiscal year lists failure to obtain informed consent requirements as one of the most common violations (2%) by clinical investigators in clinical trials. In a selected practice site, approximately 440 (2%) out of 25,000 paper informed consents were returned by the medical records department to clinicians in 2019 due to incomplete and or inaccurate information. This resulted in significant delays in the start of clinical trials, incurring additional time and effort for participants and clinicians to correct and or re-consent.

Purpose: The purpose of this quality improvement project is to implement electronic informed consent for research participants in the adult oncology, allergy and infectious disease, and diabetes, digestive, and kidney diseases outpatient clinics in a clinical research hospital.

Methods: Pre-implementation surveys were administered to clinicians (n=43) to obtain baseline perceptions on using paper versus electronic consents. The clinicians were then trained remotely on using electronic consent for signatures. Paper consents were replaced with electronic consents for specific protocol studies (n=8), followed by a post-implementation survey to compare clinicians’ preferences and satisfaction.

Preliminary results: Preliminary results show an increase in the mean percentage of confirmed electronic informed consents accessible in the electronic health record within one day of signing by clinicians. However, the results of the project have not yet been completed. The plan will be to discuss the findings for documentation of informed consent, timeframe for accessibility of confirmed consents in the electronic health record, and clinician satisfaction with using electronic informed consent.

Preliminary conclusions: Preliminary conclusions show that replacing paper with electronic informed consent appears to improve documentation. However, the results of the project have not yet been completed, and therefore conclusions cannot be drawn at this time. 

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Evaluation of an Online Educational Module on Nursing Students' Perceived Abilities and Knowledge about Telehealth Nursing

Identification: P43

Purpose: The purpose of this study was to evaluate a newly designed online educational module on the use of telehealth nursing in ambulatory care settings. Bachelor of nursing (BSN) students who completed the module rated their overall knowledge of the content and their perceived abilities to actualize the content, manage clients, and educate and mentor others. The development of the module was supported by the CARES Act supplemental funding for NEPQR program to prevent, prepare, and respond to COVID-19.

Background/significance: Telehealth nursing has become an essential skill for nurses due to COVID-19; however, training resources remain scarce for pre-licensure nursing students. To meet this need, an online module was developed, implemented, and evaluated in a BSN program at a large academic university in fall 2020. The module focused on 1) the definition of telehealth nursing, 2) professional telehealth communication strategies, 3) handling difficult situations, 4) use of medical interpreters, and 5) telephone triage. The triage section emphasized the nurses’ scope of practice and the use of decision support tools. The self-paced interactive online module included two exemplar case studies to demonstrate the promotion of diversity, equity, and inclusion using telehealth nursing and a downloadable toolkit.

Methods: The BSN students were asked to participate in an anonymous 6-question mixed-method survey upon completion of the online module about telehealth nursing. The participating students rated their pre- and post-module abilities to actualize the training content, level of comfort managing clients, overall knowledge, and ability to educate others about telehealth nursing using a 5-point Likert scale (1=low, 5=high). The survey also included a free-response feedback item. The survey responses were compared using a paired T-test. Study procedures were approved by the university’s institutional review board.

Results: 13 of the 83 students (16%) agreed to participate in the study. Overall, the students’ self-rated post-module expertise was significantly higher for all questions compared to the pre-module expertise (p < 0.05). On average, the students rated their post-module abilities to actualize the training content higher by 1.3 points (95% CI: 0.7-1.9), as well as the abilities to manage clients (1.4 points, 95% CI: 0.9-1.9), level of comfort (1.5 points, 95% CI: 1.0-2.1), overall knowledge (1.3 points, 95% CI: 0.8-1.8), and ability to educate others about telehealth nursing (1.1 points, 95% CI: 0.6-1.5) compared to their pre-module levels, respectively. The qualitative responses described the case studies and interactive learning platform as helpful and provided technical usability feedback such as playback speed and glitches.

Conclusions/implications: The telehealth nursing online module improved the BSN students’ perceived abilities to actualize the content, manage clients, educate, and mentor others and overall knowledge about telehealth nursing in ambulatory care settings. Additional educational resources are needed to equip nurses to deliver high-quality care and meet the increasing demand for telehealth nursing.

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

The Use of Web-Based Health Education among Safety-Net Ambulatory Care Clinic Adult Diabetic Patients

Identification: P50

Background: A large public safety-net hospital system implemented a web-based video education program to improve chronic disease management outcomes. Using animation and a calm engaging voice, the program explains complex medical information and directs patients on making healthy lifestyle choices and decisions regarding their care. Patients receive notification that web-based education has been ordered for them either verbally by a care team member, on an after-visit summary, or through the organization’s patient portal. The video is then accessed via smartphone, tablet, laptop, or desktop computer. If the video is not accessed by the patient or caregiver within 6-8 weeks, the order expires and is no longer available. Initial evaluations of the initiative found that patients who completed the web-based education reported the program: “helped them manage their health”, “answered questions they would have called their doctor to discuss,” and “motivated them to change their lifestyles.” However, the video programs were viewed by a very small number of patients and little was known about the profile or demographic make-up of the patients who were most likely to complete the videos. Without this information, determining how to reach the most complex patients is a difficult task.

Purpose: To identify factors associated with the use of an online, web-based health education program among diabetic patients at five ambulatory care clinics of a large public safety-net hospital system.

Methodology: A retrospective chart review of the electronic health record was conducted. Diabetic patients who had active orders for the web-based programs were identified on patient registries.

Analysis: Mean, frequencies, and percentages were calculated to the describe sample. Chi square, t-tests, ANOVA, and multiple regression were used to answer the research questions.

Results: N=300. Only 5.3% (16) patients completed the diabetes type 2 education video, and 9.3% (28) completed the diabetic eye exam education video. Patients who completed a web-based video more likely to be younger, caucasian, living outside of inner-city core, and users of the organization’s patient portal; they were also more likely to complete their annual diabetic eye exam. No association between the completion a web-based video and gender, number of clinic visits, number or type of co-morbid conditions, or medical insurance. Use of patient portal was the most predictive variable for completing at least one web-based video, completion of diabetic eye exams, and improving hemoglobin A1c.
Conclusion: The use of eHealth technology has great potential to empower patients to take a more active role in managing their health conditions and ultimately achieving improved health outcomes as seen with the results related to diabetes management in this study. To maximize the positive impact of eHealth and web-based disease management support tools, health care organizations must consider barriers to the use of these tools. Future research will focus on strategies to address issues of access to digital devices, eHealth literacy deficits, and varying comfort levels with the use of the evolving technology.

Learning outcome: Describe factors influencing use of technology for patient education at a large public safety-net hospital system.

• After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.

Addressing the Mental Health of Registered Nurses during the COVID-19 Pandemic

Identification: P53