Purpose/description: Due to distancing requirements forced by the COVID-19 pandemic, access was challenging in our hospital-based, five-bed pediatric infusion therapy center (PITC). This, accompanied by several other factors, contributed to a less-than-optimal patient experience, especially for patients who had clinic appointments and chemotherapy on the same day, but in different locations. Providers, patients, and families were vocal in sharing their dissatisfaction regarding convenience, location, and length of day with appointments(s) and infusion(s).
Prior to the pilot, pediatric patients were scheduled to have laboratory specimen collections, lumbar punctures, and clinic appointments in one location, and then were required to travel to the hospital based PITC to receive their 15-minute chemotherapy infusion. Depending on availability in the PITC, some patients would wait hours between appointments and their infusion, be admitted to the hospital, or receive their infusion in an adult infusion therapy center. Further, the clinic space and hospital based PITC are located 10 blocks from each other, adding inconveniences associated with travel and parking.
An interprofessional team was formed to evaluate current medications administered in the PITC and assess for feasibility of administration in our ambulatory care pediatric oncology clinic space. In this model, access would be opened for longer infusions to occur in the PITC by offloading infusions that were shorter in duration. Criteria such as duration of infusion, risks for adverse reactions, location of drug storage, and billing implications were assessed. Guiding principles were identified for the project, with patient safety identified as the top priority. Also prioritized was the provision of care for pediatric patients in pediatric locations.
Five chemotherapy drugs, two colony-stimulating factor medications, and three anti-emetics were originally selected as drugs that could be safely and efficiently given in the ambulatory care clinic setting.
Results/outcome: During phase I, 25 unique patients safely received a total of 52 chemotherapy infusions in the ambulatory care clinic setting. There were no patient events reported related to the infusion pilot. 100% of eligible patients received their infusion in the ambulatory care clinic location. The interprofessional team significantly reduced the number of pediatric infusions administered in the adult infusion therapy center. Due to the success of phase I, the team expanded access and the number of chemotherapy drugs to be infused as part of phase II. Nearing the end of phase II, 52% of available slots were utilized. Four chemotherapy drugs and one anti-emetic were added. In total, nine chemotherapy infusions can now be administered alone or in conjunction with a second chemotherapy infusion in the ambulatory care clinic setting
A limited trial of chemotherapy infusions was shown to be safely and efficiently administered in an ambulatory care clinic setting. The coordination of laboratory specimen collections, appointments, and chemotherapy infusions in one space was appreciated and preferred by patients and families. Offloading shorter infusions from the PITC to the ambulatory care clinic setting improved access for longer infusions in the PITC.
This presentation outlines program results since 2019 of a 6-month intensive university led post-baccalaureate residency/fellowship designed to prepare practice ready RNs in primary care. This program is part of a HRSA-funded program with specific goals to enhance capacity of BSN-RNs prepared to work to their full scope of practice in primary care settings and to develop RNs with skills to be able to articulate the value proposition of the expanded role in community-based primary care settings .
Presenters will provide outcome data from the residency/fellowship program, which has, in addition to developing highly trained RNs for practice in primary care, also supported integration of RNs into the primary team through partnerships with area practices.
The competency-based curriculum was developed using “reverse engineering” through intentional data collection from practice partners and RNs practicing in primary care. The robust program includes practicum immersion, didactic continuing credit-bearing modules, and a variety of simulation experiences, to support development of skills in addressing medical emergencies in the primary care setting, conducting annual wellness visits, interprofessional co-visits with social work, and development of telephonic assessment skills, including use of telephone triage protocols.
Of the 25 program participants to date, 43% were new graduates. Of four cohorts who have completed the program to date, an average of 81% are practicing in community and primary care settings. Additionally, through partnerships and technical assistance provided by the university to multiple agencies, practice partners have experienced significant expansion of RNs being embedded into the practice. Program graduates have assumed both clinical and leadership roles within the agencies in which they fulfilled their residency/fellowship practicum.
The presenters will also discuss future sustainability plans as well as lessons learned to inform other agency and health systems interested in developing primary care-focused residency/fellowship programs.
Introduction: Whether routine screening for depression among patients in primary care medicine improves identification and treatment of the disorder remains unclear. We conducted a systematic review of the literature to address the following questions specific to this population: 1) how well do screening tools detect depression?, 2) does screening lead to diagnosis, treatment, and improved outcomes?, and 3) analyze our performance in screening and treating mental health conditions during the pandemic in order to increase the rate of clinical improvement in depression scores from 16% in January 2020 to 66% by December 2020.
Methods: We searched bibliographic databases for full-length articles published in English around COVID pandemic from January 2020 to December 2020 and articles from previous years on depression in primary care settings and completed a review of our own primary care patients screened and treated during this time.
Results: Screening process amongst out patient population has improved the patient’s receipt of diagnosis and treatment. Effective treatments include exercise, psychotherapy, and pharmacotherapy.
Discussion: The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders. To assess mental health and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years. The pandemic interrupted routine screening and in-office visits. Retraining of staff/providers was needed to complete PHQ2/9 during video visits.
Analysis were stratified based on primary drivers like depression screens, documentation and patient engagement, and our secondary drivers like workflow and process improvement consistent documentation of PHQ9 screening and increase patient attendance to therapy appointments. We were able to accomplish this, and mitigate activities around staff and provider trainings to complete telephonic visits that led to high-connection rate, workflow review at huddles to reinforce paper screening alongside with electronic data entry, electronic screenings utilizing Epic flowsheets and co-location of therapist-collaborative care therapist in primary care. This improved our access to trained staff for referrals and discussions at team meetings with psychiatrist for consultation and then recommendation to start medication as needed.
References
1) Williams JW Jr, Pignone M, Ramirez G, Perez Stellato C. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry 2002;24(4):225-37.
2) Mark É. Czeisler, Rashon I. Lane, MA, Emiko Petrosky, MD, Joshua F. Wiley, PhD, Aleta Christensen, MPH, Rashid Njai, Matthew D. Weaver, PhD, Rebecca Robbins, PhD, Elise R. Facer-Childs, PhD, Laura K. Barger, PhD, Charles A. Czeisler, MD, PhD, Mark E. Howard, MBBS, PhD, Shantha M.W. Rajaratnam, PhD Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020 Weekly / August 14, 2020 / 69(32);1049–1057
Objectives: Identify the role of the emergency department clinical nurse leader (CNL), focus of practice in a community hospital, and key care coordination strategies used.
Background: The CNL role quickly spread to all inpatient units at an organization since implementation in 2012 and is now fully operational in the emergency department. The CNL focuses care coordination, organizational initiatives and education, and quality measures. The ED is a unique ambulatory care setting that is a gateway for the community to either access the hospital or connect with outpatient resources. Making connections for complex patients and vulnerable populations is at the heart of the ED CNL role.
Methods: The ED CNLs optimize interdisciplinary collaboration by functioning as a connector for care across many clinical settings. One key intervention that the ED CNL leads is that of the creation of complex care plans for the highest utilizer patients in collaboration with physicians, social workers, and other pertinent departments. Connections with primary care ambulatory care sites are achieved as well as community partnerships, tracking patient progress, and making personal connections with patients.
Practices: ED CNLs aim to reduce hospital readmissions and ED utilization through a multi-faceted transitions management program. Elements of the CNL role center on the RN as care coordinator which is vital in today's healthcare environment.
Outcomes: The success of the CNL has been due in large part to positive change in 30-day hospital readmissions, length of stay, core measures, and other patient outcomes. The CNLs have developed complex care plans for the highest ED utilizers to help reduce 30-day all-cause hospital readmissions. Additionally, the ED CNLs have begun to more intentionally create a pipeline for patients to primary care providers.
Recommendations: ED CNLs continue to broaden their scope of impact on chronic and vulnerable populations. CNLs to continue to engage with ambulatory care clinic nurses and other health systems to sustain the important connections being made through complex care plans.
Purpose: The purpose of this quality improvement project was to improve outpatient medication review and reconciliation through the introduction of nursing. It is understood that active health professional medication management assists patients in maintaining complete and correct medication lists. This in turn helps improve the patient’s medication awareness, sustains overall health, and promotes long-term wellness. Despite the benefit of medication review and reconciliation, fragmented outpatient visit processes result in medication lists not being reconciled between what is prescribed and what the patient is self-administering. Multi-factorial reasons have been outlined as to why the licensed prescriber may not resolve these discrepancies; however, the lack of action taken has resulted in compliance rates as low as 60% within the studied practice settings. Published evidence notes that many adults often partially or completely omit prescribed medications. Non-adherence has been estimated to contribute $290 billion annually to national health system spending. Shared effort towards improved medication management inclusive of nursing has demonstrated an increase in complete and correct improved problem anticipation and a potential reduction in adverse medication events.
Description: Two outpatient clinical areas were selected for a 15-week intervention. One caring for primary care/infectious disease patients and the other a surgical otolaryngology practice. Between the practices, 17 nurses are employed. The reviewed encounters were primarily made up of prescriber appointments but also included nurse exclusive visits. Further, nursing telephone triage encounters were included in the intervention. Workflow changes included nurse education on proper medication review and reconciliation, establishment and instruction on the preferred workflow, and EHR workflow enhancement. Nurses during in-person clinic visits and during appropriate telephone encounters were directed to review and reconcile current EHR records. Medication reconciliation compliance was measured through the recorded completion of the activity. Those patients engaging in an in-person encounter were provided a paper version or directed to the e-version after-visit summary for an updated and valid medication list. Press Ganey© CG-CAHPs rates, specific to medication management, were also reviewed.
Evaluation/outcome: Overall compliance and specifically nursing compliance contribution was measured. Reconciliation compliance data at baseline was 81.5% for the primary care and 74.7% for the otolaryngology setting. Overall reconciliation slightly improved to a high of 90.4% within the primary care and 86.2% within the specialty setting. The primary care overall nurse attributed compliance rate was 2.9% with a high of 4.4% at week 4. The otolaryngology practice recorded an overall rate of 22.8% with a high of 30.8% at week 6. Nursing exclusive encounters demonstrated a 30-40% reconciliation improvement. Medication review and reconciliation management during telephone encounters was minimal with a high of 2.5% during week 7 of the intervention. Patient satisfaction data was unchanged in the primary care practice setting and demonstrated a 13% positive change from baseline in the otolaryngology.
Purpose: The purpose of this evidence-based research pilot project was to identify current practice for adolescent suicide screening in primary care and the role of the RN in this process.
Background: Suicide is the second leading cause of death among adolescents and young adults in the United States (CDC, 2019). It is crucial for nurses working in all settings, including primary care, to be able to recognize and respond to suicide risk and suicidality in the adolescent population. In individuals that died by suicide, 45% of them had a visit with their primary care physician a month before death (Hogan & Grumet, 2016). This inquiry aimed to answer the question “What does adolescent suicide screening look like in primary care and what is the role of the RN in this process?”
Methods: A multi-method approach was utilized. First, a review of literature was conducted in August 2021 using a combination of MeSH terms and Boolean operators in the following databases: CINAHL, PubMed, and SCOPUS. Next, semi-structured interviews were conducted with four primary care team members, including two RNs, one MA, and one FNP.
Results: The initial literature search yielded 4,544 articles. Application of the inquiry inclusion/exclusion criteria markedly reduced this number; 486 studies were published in the last 5 years, 70 studies included key search terms: suicide, primary care, adolescents, and nursing. Only four studies discussed the role of the RN. Interview participants reported MA’s initiate the suicide screening process with handoffs to providers. The RN role is limited. All participants (n = 4) expressed feeling mostly confident, comfortable, and competent in conducting suicide screening, yet they all expressed a desire to receive additional training on suicide screening, especially around how to talk to patients about suicide. Of note, the primary suicide screening instrument utilized is the PHQ-9. Finally, participants acknowledged a gap in the need and availability of behavioral health staff.
Conclusion: The interview sample size was small with only four interviews across two clinics; however, the results show a potential gap in practice where suicide is not being specifically screened in patients. There does not appear to be a universal suicide screening tool (or process) for adolescents in primary care. Further research should focus on validating a suicide-specific screening tool for adolescent populations in primary care or universally across multiple settings. While RNs may not have a prominent role in suicide screening and assessment in primary care, they currently fill this role in the ER and mental health units. RNs have the ability to assess patients and make well-reasoned clinical decisions. Based on the findings, it is entirely possible for a patient with suicide ideation to have contact with the receptionist, MA, provider, and behavioral health staff – completely circumventing the RN. More research needs to be done involving the role of the primary care RN in adolescent suicide screening.
Purpose: As healthcare focus shifts from the hospital environment to ambulatory care, collaboration among leaders is essential. The volume of patients in ambulatory clinics is growing and the care nurses are providing is becoming more complex. When an ambulatory care system employs a staff development specialist (SDS) and a clinical nurse specialist (CNS), it makes sense for these leaders to collaborate to improve quality of care, yet minimal literature exists to demonstrate the impact of the SDS/CNS collaboration on the ambulatory care enterprise. The purpose of this quality improvement project was to evaluate the SDS/CNS collaboration through the use of the PLAN-DO-STUDY-ACT model to improve quality and carry out change related to the use of pain score assessment in a large ambulatory care system.
Description:
PLAN: Joint Commission requires accredited ambulatory care organizations to use defined criteria to assess pain and our organization’s policy requires a baseline pain assessment is completed upon each initial contact with an ambulatory care patient. Our internal accreditation team audits identified a gap in care. Upon further investigation by the SDS/CNS, only 13.5% of patients were assessed for pain upon each initial contact in January 2021. We developed a plan to address this gap and presented our plan to the ambulatory care shared governance council and incorporated education into ambulatory care clinical orientation. We developed and completed an attestation form for all clinical staff, documenting understanding of the pain policy which was completed by May 31. To aid in pain assessment, a tool was developed and distributed in the form of a pocket card. Follow-up emails and discussions with data were sent monthly to ambulatory care leadership to reiterate compliance.
DO: The above plan was implemented as indicated.
Evaluation/outcome:
STUDY: Our baseline rate of pain assessment in January 2021 was 13.5%. By March, it was 18.91%, and by April, it was 26.76%. At the end of May 2021, it was 35.32%. Within this brief time frame, 2.4 times more patients are now being assessed compared to baseline, indicating significant improvement resulting from this collaborative quality improvement project.
ACT: Data is ongoing. The organization transitioned to a new EHR (Epic) starting June 5. We intensely educated clinical staff on how to document the pain score in the new EHR system through hands on education and visual workflows to further enhance compliance.
The United States opioid crisis is considered a public health emergency due to the deaths associated with drug overdose, with more than 60% of deaths involving an opioid. The focus of the project is to standardize the prescribing and monitoring process for scheduled controlled substances in primary care.
The project outlines a detailed process for organizations to choose a maintenance model for opioid patients that will work despite staffing mixes or EMR functionality. Additionally, it assists the primary care team in properly evaluating the patient risks and aligning their prescribing practice to evidence-based guidelines, creating a consistent approach for all patients.
The project can be utilized by various staffing mixes. Our project begins when the patient is on a stabilized opioid dose. At this time, nursing and/or advanced practice providers can screen the patient utilizing various methods and tools to appropriately refill the patients opioid medications in between primary care office visits. In addition to consistent screening processes, nursing and advanced practice providers can appropriately educate on naloxone prescribing, prescription drug monitoring, and proper pain consents.
The goal of our project is to involve nursing and/or advanced practice providers in the opioid screening process to support prescribers with their efforts to safely prescribe and educate about opioids.
References
1) Simonette, P., Hernandez, M., Irizarry-Pelletier, J., McNeil, S., & Orfitelli, J. (2020). Nursing Care and Patient Safety with Opioid Use in a Primary Care Setting. View Point, 42(3), 3-6. Retrieved February 5, 2021
The recent coronavirus pandemic has exposed the healthcare systems’ deficiencies in prevention and management of chronic illnesses. This resulted in devastating morbidity, mortality, and healthcare costs. The current reactive and episodic disease-oriented healthcare system must shift to prioritize proactive primary care for diverse populations through chronic disease management, and health promotion and wellbeing.
In primary care settings, registered nurses who work at their full scope of practice and licensure contribute to improved patient outcomes. Yet, many RNs are not aware of, or prepared for, primary care roles because undergraduate nursing education has traditionally focused on acute care. As recommended by the Josiah Macy and Robert Wood Johnson foundations, curricula enhancements to increase primary care nursing skills in undergraduate nursing education are needed. The purpose of this presentation is to describe the development and implementation of a new online primary care elective course offered to prelicensure and postlicensure nursing students.
In this online course, students learn about primary care delivery business models and expanded nursing roles, such as health coaching, chronic disease management, and coordination of care. Other topics include health promotion and education, oral health assessment, health literacy, patient-centered communication, mental health screening, medication adherence, patient empowerment, chronic disease self-management, social determinants of health, and integration of technology to improve health outcomes. The course includes a module on self-care and resilience building strategies. Students also participate in an experiential interprofessional telehealth workshop.
Interest in the primary care elective course has exceeded expectations with 49 students enrolling in the first semester offered. Student feedback has been overwhelmingly positive. 100% of the students who completed the end of course evaluation agreed or strongly agreed that the course enhanced their learning. They described the content as “useful, practical information that I can easily apply to my practice.” In a pre-test/post-test comparison of knowledge scores of multiple primary care topics, self-reported mean knowledge scores increased significantly. Students listed preventative care, vaccine recommendations, communication skills, depression screening, alcohol misuse screening, telehealth etiquette, self-care resources, health coaching, and more as specific skills and knowledge that directly applied to their clinical practice.
A discussion of content, resources, teaching strategies, and lessons learned will assist other educators in developing primary care content for their own curricula. A course outline and sample assignments to jumpstart course development are offered for distribution. Instructional videos using standardized patients to demonstrate screening for depression and alcohol misuse as well as telehealth etiquette and patient-centered communication are housed on a HRSA grant-supported website that will be shared as a free open access resource.
Purpose: The purpose of this project was is to test whether an enhanced role of nursing in primary care could improve diabetes care and outcomes.
Goal: The goal of the project was to enhance the role of the care team RN, allowing them to work to the highest of their licensure and improve the health of patients with diabetes, develop sustainable workflows and practices that would improve our quality metrics. All tools and processes developed were to be translatable to other chronic diseases in the future. This approach is proactive and longitudinal where nurses engage patients in their care and collaborate with the multidisciplinary teams.
Description: A literature review was completed, and working with a multidisciplinary team, interventions and workflows were developed to address each element of optimal diabetes control. Understanding the elements of optimal diabetes care resulted in complex workflows. To ensure the patient-centered workflows were followed consistently, a decision support tool was developed to result in consistent actions and best practice recommendations to assist in improving patient outcomes.
Utilizing the decision support tool, the nurses review the patient’s medical record, determine opportunities for improvement, make referrals to supporting departments, and recommend actions to providers. In addition, the nursing staff reaches out to patients to discuss healthy lifestyle changes, collaborate on ways to improve the patient’s health, and address barriers that prevent the patient from taking an active role in self-management of their chronic condition.
A resource guide, toolkit, and webpage were developed to support teams. Electronic health record (EHR) tools were enhanced to optimize documentation to include patient activities and outreach which allows the teams to follow-up with patients on a routine basis.
Initial education was provided to nursing staff. In follow-up, a diabetes bootcamp for nursing was developed as an on-demand program that will be used to refresh current nursing teams on workflows and orient new nurses to the established processes. The bootcamp includes information on understanding diabetes, medication therapy management (MTM) pharmacy and nutrition resources, viewing quality data, motivational interviewing, setting smart goals, and examples of how nurses changed their practice and patient outcomes.
Evaluation/outcome: 30 primary care teams across multiple sites initiated this nurse led intervention with staggered start dates. The average percent of patients meeting optimal diabetes care prior to implementation was 37%, with no teams meeting the 50% goal. Challenges included differing team compositions, resources, and COVID-19. Despite the challenges, as of June 2021, this transformational nurse-led intervention has resulted in 13 out of the 30 teams now meeting the 50% goal of optimal diabetes care, with many more teams approaching the 50% mark.
Future implication and learnings: This project has demonstrated that improving diabetes control is highly impacted by nursing interventions. Optimal outcomes are achieved through prioritization of quality outcomes across all levels of the organization. This can be accomplished by having formal and informal conversations related to quality, establishing accountability mechanisms, sharing data regularly, developing a collaborative work environment, and encouraging a team-based approach to improvement.