In 2020, the COVID pandemic rapidly spread throughout the globe. News of its spread and impact on communities dominated television and media outlets as healthcare facilities were overwhelmed with an increasing census of severely ill COVID patients. A mid-sized county hospital in West Texas experienced its first case on March 18, 2020. Quickly the organization’s 24-hour nurse call center became a source of communication for the community as people sought answers from their local healthcare experts.
From the beginning of the pandemic, the call center was marketed as the central location for COVID information, COVID testing scheduling, and symptom triage. This reduced the burden of inappropriate visits to the emergency department and gave the community one number to call for all their COVID concerns. It also provided a referral source for our primary clinics and other providers within the health system. Patients were referred to the call center for all their COVID screening and testing needs before their appointments and scheduled procedures. Due to increased call volumes, there was a need for additional staff. When surgeries and procedures were canceled in outpatient locations, many nurses working in these areas were trained to take calls to assist in the call center. This helped prevent furloughs of nursing staff within the hospital.
In hopes to continue to mitigate the spread of COVID and now its many variants, healthcare facilities are working to help get community members vaccinated. For the organization, the effort to open a mass vaccination site required work from many different areas within the health system. The 24-hour nurse call center became an integral part of this process. When the organization was designated as a vaccination hub for Texas, the call center was asked to assist with mass vaccination appointment registration and scheduling. By utilizing the 24-hour nurse call center, the organization was able to successfully manage over 1000 additional calls per day to help schedule patients for COVID vaccinations. In total, over 70,000 people were vaccinated at the vaccination site during the 4 months it was open. Individuals traveled from all over the state of Texas and even out of the country to our site to receive COVID vaccinations. The steps involved in leveraging the flexibility of a 24-hour nurse call center to adapting healthcare access will be discussed along with lessons learned, challenges experienced, and successful outcomes achieved.
Background: According to the CDC, a sharp increase in sexually transmitted infection (STI) rates resulted in the highest documented rates in six years (2019). This includes an increase of 42% in gonorrhea, 61% in chlamydia, and 50% in syphilis. Men who have sex with men (MSM) represented 55% of all STI cases (CDC, 2021). Researchers fear an upsurge in STI rates may be due to an increasing obstruction of routine preventative care. While the CDC’s data was captured prior to the COVID-19 pandemic, the global pandemic may be a barrier to regular STI testing in MSM. The purpose of this nurse-led quality improvement project was to improve rates of STI testing with accelerated treatment in MSM during the COVID-19 pandemic.
Methods: A nurse-led, quality improvement project was implemented using a PDSA framework. In phase one, an interdisciplinary group (physician, advanced practice provider, nursing) met to develop a plan to optimize expeditious access to STI screening, testing, and treatment. In phase two, the nurse-led interdisciplinary group developed an STI screening tool and education was provided to the clinical team on utilization. STI protocols were standardized and included a COVID-19 screening. In the protocol, positive STI and COVID-19 screens are identified by the nurse, followed by nurse-led order entry of standing STI and site-specific labs including oral, rectal, and urine specimens. The standardized protocol allows the nurse to conduct in-person, STI testing in the clinic setting, and allows expeditious test results prior to a virtual provider visit. For positive tests, treatment is initiated the day of the virtual visit with the provider. In phase three and four, the nurse will perform audits to collect quality data to enhance the protocol, with targeted interventions to address practice gaps.
Results: From October 2020 to April 2021, 559 patients completed the nurse-led STI screening questionnaires and 249 patients received site-specific STI testing. The positive STI rate was 14.8% with time to initiation of STI treatment reduced to less than one day.
Baseline STI testing rates in 2018 to 2019 were 9.7%. Following implementation of the nurse-led protocol, the testing rate increased to 17.4%.
Discussion: Using a PDSA framework, implementation of a nurse-led STI screening and testing protocol demonstrated improved patient outcomes. Despite COVID-19 being an added barrier to STI testing, STI testing rates increased during this time period using a nurse-led STI protocol. As the protocol continues with further PDSA cycles, we anticipate further enhancements with increased testing rates.
There is an exciting paradigm shift from inpatient to ambulatory care in healthcare. This comprehensive metropolitan cancer center identified that ambulatory care nurses needed confidence and competence in the complex skill set required to ensure quality and safe patient outcomes. In response, a series of courses were designed to facilitate transitioning nurses to be leaders in the ambulatory care setting.
The ambulatory care nurse role is unique and requires a specialized skill set that goes beyond traditional acute care. As this shift generates new and experienced nurses into the ambulatory care setting, this drives a need for a focused and formal education (American Academy of Ambulatory Care Nursing (AAACN), 2018). To facilitate successful role transition this organization developed an evidenced-based, continuing education course, the role of the oncology nurse in the ambulatory care setting. This course is patterned after national professional organization standards, regulatory requirements, state, and internal policies and guidelines.
Comments from post-evaluations recognized the need for broadened education. In response, an ambulatory care nursing role series evolved to consists of three courses. The role of the oncology nurse in the ambulatory care setting, which focuses on developing skills for the RN to be poised to lead the ambulatory care team, including role components, coordinating care, and effectively communicating within internal and external environments to promote quality care for the patient and the family. A debrief is conducted one-month post-attendance. Participants are reporting a positive change in their nursing practice. A post-formative assessment revealed a 25% increase in knowledge. The role of the oncology nurse in telephone triage provides the nurse with tools and resources necessary for this unique role, including symptom management protocol, effective communication, ethical and legal situation management, and proper ergonomics. The Greenberg model is utilized, providing the basis for guiding practice to implement care within a clinical setting. Learning is validated through simulation and role playing, with observed skill improvement. Participants complete a post-formative assessment, and a 43% growth in knowledge was appreciated. Lastly, documentation in the ambulatory care setting plays an important role in coordination of care. The role of documentation in the oncology ambulatory care setting explores state-of-the-art best practices to provide the nurse with the understanding of the value of clinical documentation. Documentation outcomes are being measured collaboratively with the quality and safety department.
All three post-course evaluations show an 85-95% satisfaction rate, and staff report the ambulatory care series as valuable to their role and describe it as “overdue,” “more confident in my role,” and “extremely valuable.” Next steps include creating content to support the recent expansion of telehealth in the ambulatory care setting.
The multifaceted and complex setting of ambulatory care is rapidly growing, and the roles are expanding. The ambulatory care nurse is the leader of outpatient care and the liaison for the patient, the family, and the community. The RN new to professional ambulatory care requires specific knowledge, tools, resources, and support to lead the future of the evolving ambulatory care setting.
Background of the problem: Patients with heart failure (HF) may have stressful lifestyle changes. Patients with HF in our clinic show signs and symptoms of depression but, often times have never been screened. In a literature review, depression was often undiagnosed. Patients with HF and depression had higher rates of morbidity and mortality compared to patients without depression. Assessment of depression can be completed by a psychologist/psychiatrist using specific criteria, or more simply, via a patient-reported outcome measure (survey).
Objective: Review current literature to determine the best depression screening tool for patients with heart failure.
Methods: The librarian at our hospital was consulted for the article search. The keywords and medical subject heading (MeSh) search terms were heart failure, depression, depression tools, depression screening. The inclusion criteria was as follows: research of patients with heart failure, included at least 2 depression screening tools, or was a systematic review or meta-analysis. The exclusion criteria are case study, depression tool was not assessed for its relationship to other depression measures, expert opinion/review paper, and editorial.
We used the PubMed as our search engine. We retrieved papers from the previous 5 years, then extended the search to 15 years as seminal work was completed (SADHART-CHF study).
We found 56 articles that related to our topic objective. We excluded 19 papers after initial review. In total 37 papers reviewed. However, all but 5 papers used only 1 depression tool or met exclusion criteria. Five papers reviewed on the topic objective
Outcomes: Of 5 reports, only 3 used 2+ depression tools that allowed us to determine if one method was best. The other 2 reports used 1 depression tool and patient interviews by experts to determine depression based on published criteria for DSM IV (diagnostic criteria for major depressive disorder and depressive episodes). When depression prevalence was compared, rates of depression were higher when using patient-reported depression survey tools.
Conclusion: 18 depression tools were used in the studies that were reviewed. More than 1 depression screening/assessment method was used to assess depression in only 5 published reports. No researchers used the same 2 assessment tools to learn if 1 was superior to another in identifying depression. Although we were unable to determine superiority; tool sensitivity varied among different research studies and when using DSM-III or IV criteria, depression rates were lower than when using survey tools.
Implications for nursing practice: Depression may be identified by survey during a clinic visit. Since no 1 survey was superior, ANY valid, reliable survey should be used; preferably one that has been used in patients with heart failure AND preferably, once that has consistent results based on DSM-IV depression criteria.
More research is needed to determine if 1 depression survey has higher precision than others, especially since some are less burdensome and since some led to higher depression rates than using DSM interview criteria. Many research papers were not contemporary (>10 years old). It is unknown if patients on current heart failure therapies have similar depression rates.
Performing procedures is becoming a common practice in ambulatory care clinics. Providing comfort during these procedures often requires the patient to receive local anesthesia via injection. Clinics with providers such as dermatology, can use a substantial amount of local during certain procedures. With this practice becoming more frequent, the subject of L.A.S.T syndrome was introduced and questioned. Upon investigation it was discovered that there was lack of policy, protocol and education surrounding L.A.S.T syndrome in ambulatory care. L.A.S.T. syndrome, or local anesthetic systemic toxicity, is a serious life-threatening condition that can occur in any setting following the administration of local anesthesia. This must be rapidly recognized and treated to improve the patient’s chance of survival (AORN, 2021). Following the identification of this practice gap a team was developed. This team was tasked with obtaining the latest evidence-based practices and guidelines to establish a policy and protocol for rapid recognition and treatment of L.A.S.T syndrome in ambulatory care across the healthcare system. A policy and protocol based on EPB and guidelines was successfully developed, equipment and rescue medication were obtained, and nursing staff was provided education via in-services, educational materials and low-fidelity simulation. Expected outcomes included: Nursing staff will be able to recognize patient risk factors, monitor for and detect the early signs and symptoms of L.A.S.T, provide rapid treatment via the ASRA (2020) algorithm, and effectively transfer the patient to the next level of care following provided education and simulation. Implementation of this practice elevated staff confidence in recognition and management of L.A.S.T syndrome and improved ambulatory care procedural patient outcomes.
References
1) AORN. 2021. Local Anesthesia. Retrieved from: Local Anesthesia | AORN eGuidelines+ (aornguidelines.org)
2) ASRA. 2020. Checklist for Treatment of Local Anesthetic Systemic Toxicity. Retrieved from: Checklist for Treatment of Local Anesthetic Systemic Toxicity (asra.com)
Purpose: Since the capricious and unprecedented advent of COVID-19, normalcy has been altered in myriad ways for both patients and healthcare professionals (HCP). Bi-directional risks of contagion (provider-to-patient, and vice versa), preservation of personal protective equipment, and mitigating the impact created by patient surges have transformed how and where patients access care (Centers for Disease Control and Prevention [CDC], 2020). Identifying ways of communicating effectively and continuing care for clients during the global crisis has become imperative, including more reliance upon digital platforms (Blandford, Wesson, Amalberti, AlHazme, & Allwihan, 2020). Telehealth is not new, but many HCP and patients were reticent about widespread adoption prior to the pandemic (Orlando, Beard, & Kumar, 2019). Our healthcare system is affiliated with two medical schools with frequent rotations by different medical students/residents. As tenured care providers, a team of clinicians and nurse leaders implemented an evidence-based practice initiative to explore innovative pathways to promote interprofessional and patient-engaged communication and enhance delivery of safe patient care.
Description: A PICO question was developed to guide the retrieval of salient literature: “Among potentially disenfranchised patients who traditionally seek care in the ambulatory care services of a safety-net healthcare system (P), does the integration of innovative, nurse-driven educational modalities facilitate (I) or impede (C) interconnected approaches to assessment, proficiency enhancement, and care delivery (O)?” Literature (N=151) was retrieved from Nursing Reference Center Plus, PubMed, and CINAHL. After eliminating duplicates, 21 articles met the specific inclusion criteria and were independently appraised by at least two team members using the Johns Hopkins nursing evidence-based practice criteria. Scoring discrepancies were resolved by team consensus. Appraisal ratings included: (level 1 [3 experimental]; level 2 [1 quasi-experimental]; level 3 [3 non-experimental; 2 qualitative]; level 4 [6 systematic reviews; 1 clinical practice guidelines]; and level 5 [5 literature reviews]).
Outcome: Remote access to healthcare benefits the medically or socially vulnerable, facilitates monitoring of chronic conditions and medication management, and expedites screening of patients who have symptoms of COVID-19. Incorporating multidimensional (e.g., cognitive and motivational) aspects is imperative when educating patients (Pesare, Roselli, Corriero, & Rossano, 2016). They must feel empowered to acquire knowledge about their condition and assume responsibility for their choices. A qualitative study revealed that social media can be useful in building patient awareness of their medical condition (Chan, Kow, & Cheng, 2017). Study participants (adolescents) embraced gamification as a strategy to counter negative perceptions regarding health apps. Games can promote intrinsic motivation; critical components to promote patient self-engagement in their care. Limitations regarding telehealth can include comfort with technology; particularly among older clients (CDC, 2020). Sensory and motor changes (e.g., vision, hearing, mobility) may be more problematic for older adults. However, it is a common misconception that older patients have no interest in using technology platforms.
Background: As new patients are accepted and scheduled for chemotherapy, it is imperative that the team educates the patient on the expectations during the therapy and how to manage the potential side effects. Patient satisfaction with the organization is captured from patient experience surveys through Press Ganey. In 2020, Press Ganey scores for explaining chemotherapy expectations and side effect management were below the target Top Box Score goal for the Ambulatory Care Treatment Center (ATC) League City. A literature review revealed that contacting patients via a telephone call is a convenient way to reduce chemotherapy toxicity and provide psychological support for the patient.
Objective: The objective of this quality improvement project was to develop a standardized telephone follow-up process for patients at the ATC League City who have completed cycle 1 day 1 (C1D1) chemotherapy/immunotherapy. The goal was to increase the patients’ satisfaction, as evidenced through increased Press Ganey patient experience scores related to the explanation of how to manage side effects and what to expect during chemotherapy/immunotherapy.
Intervention: Initially, education was provided to staff regarding importance of patient education with respect to explaining what to expect during chemotherapy and managing its side effects. Staff was informed to provide C1D1 patients with chemotherapy handbook and chemotherapy drug handouts.
To further develop this project, a literature review was conducted, as well as, a review of best practices for toxicity assessment for research protocol patients and telephone triage guidelines developed by Oncology Nursing Society (ONS). Based on the research findings and feedback from multidisciplinary providers, eight areas of focus were selected to develop a standardized call back process for post C1D1 chemotherapy/immunotherapy patients. Additionally, the team collaborated with nursing informatics to develop standardized documentation and prepared a tip sheet for staff on how to document the follow-up phone call in the electronic health record (EHR). A pilot project was started on August 1st, 2021 with two team members from the workgroup calling their C1D1 patients within 24-48 hours post chemotherapy/immunotherapy.
Results: Nurses engaged in the follow-up telephone call process received positive feedback from patients regarding the post-therapy assessment. The project is still in the early implementation phases, but the preliminary data have shown favorable results. For August 2021, the ATC League City Press Ganey scores for explaining chemotherapy expectations increased to 71.05% from our lowest score of 56.6% in 2020 and explaining management of chemotherapy side effects increased to 62.1% from our lowest score of 60.0% in 2020.
Conclusion: Standardizing the telephone follow-up process for post C1D1 chemotherapy/immunotherapy patients can have a significant impact in oncology patients to improve their overall expectations and side effect management post chemotherapy/immunotherapy and improve the patient experience and satisfaction.
Background/significance: The ambulatory care setting faces specific challenges when responding to medical emergencies: infrequent events, lack of standardized medical emergency plans, and inconsistent inclusion of nursing leadership in planning/oversight.
Objectives: To increase percentage of practices with approved emergency plans. To increase staff awareness of plans through formal involvement of nursing, medical, and administrative leadership.
Implementation: In 2017, the Ambulatory Care Medical Emergency Response Committee launched a medical emergency improvement project using PDSA approach. In 2020, AMERC relaunched project using data from newly completed hierarchical mapping of all locations to reassess number of practices without emergency plans. An evidence-based emergency plan toolkit was developed to guide clinicians in creating/updating plans using standardized format with new requirement for nursing and administrative sign-off along with medical director.
Performance improvement outcome: In 2020, we completed mapping of location/contact data for 442 practices. In 2021, this data was used with 2017 project data, to identify practices requiring intial or updated plans. Mapping provided ability to accurately track compliance and supports next steps in ongoing improvements. To date, outreach competed to 81% of practices and 57 % have approved plans. Using tracer data, staff awareness of emergency plan improved from 60% in 2020 to 76% in Q1 2021.
Implications for nursing practice: Nurses are well positioned to lead safety initiatives in the ambulatory care setting and are crucial stakeholders in design and implementation of medical emergency plans. By ensuring nurse participation through required nursing, administrative and medical leadership sign-off, we seek to determine if this will improve staff knowledge of medical emergency plans and later, if all components are implemented. This sets a model for future QI work using the leadership triad approach.
As part of a gold-innovated fellowship, our team identified that laboratory errors have emerged as a priority for the CHA to be addressed, as they can lead to inaccurate test results affecting patient care. The goals of this project is to achieve “zero harm” related to laboratory practices and revise processes geared toward accurate patient identification and mislabeled/unlabeled specimens. Incorporating the patient into the procedure and the testing is a critical component of our revised process.
Pre-analytical laboratory errors (defined as the time period from ordering to collection, up to the time the test is analyzed) account for up to 75% of all laboratory errors. 1 A retrospective analysis of safety reports (SERS) regarding laboratory issues filed during a period of three months, from 3/2018 to 6/2018, was performed utilizing a systematic review of 121 errors in the ambulatory care sites showed that 17.36% were related ordering, 16.53% to collection, 63.64% to transportation, and 2.48% to accessioning. These errors were analyzed to develop informed recommendations and practices to achieve the goal of “zero harm.” Of note, the lack of patient involvement was identified in the lab process.
1) Collaboration with the laboratory and ambulatory care clinics we will develop processes that incorporate both patients/family and staff to support “Zero Harm” initiatives.
2) Identification errors are uncommon (55 per 1 million billable lab tests), but they potentially can have a significant impact on patient care.
3) These errors can be a result of initial registration, order error, clerical error, primary specimen label error, aliquot error, or result entry error.
Identified the need to improve, patients/families were cited as key stakeholders. At a clinic, nurse manager and a nurse educator engaged staff in the lab to have the patient visually verify their name and date of birth at the time of collection. This simple process decreased labeling errors in that clinic to ZERO for a period of 296 days.
We have increased staff engagement and satisfaction with new tools we implemented.
Our team proposes working in a thoughtful and economical way that is future-orientated.
In conclusion as a high-reliability organization (HRO), we will continue to engage colleagues to use the safety report system (SERS) to support a culture of safety. Incorporating patients/family members and colleagues in the “zero harm” initiatives will reinforce the current culture of safety, ownership, and positivity. The team will continue supporting evidence-based procedures including the deployment of systems of safety in a consistent manner such as banding, barcoding and printing labels at registration. This process going forward will have a positive effect on the patient experience.
References
1) McPherson, Richard and Pincus, Matthew; Henry’s Clinical Diagnosis and Management by Laboratory Methods 23rd edition, Chapter 3- Preanalysis, Elsevier 2017, Pg. 20.
2) Batalden, supportsM. et al.BMJ Qual Saf 2015 :1-9. doi:10.1136/bmjqs-2015-004315
3) Identification Errors Involving Clinical Laboratories A College of American Pathologists Q-Probes Study of Patient and Specimen Identification Errors at 120 Institutions Paul N. Valenstein, MD; Stephen S. Raab, MD; Molly K. Walsh, PhD Arch Pathol Lab Med—Vol 130, August 2006, p1108
Background: Continuing clinical education is a priority in subspecialty ambulatory care clinics. Training for nursing and clinical staff within pediatric specialties typically occurs on the job and with experience over time. During the COVID-19 pandemic, opportunities for clinical teaching in real time became challenging due to social distancing.
Intervention: We developed a staff education series, with goals of improving continued education and providing a platform for connection when many of our staff were remote. Topics were created to support staff’s clinical knowledge in diagnosis, management, patient care, and practical workflows and presented by physicians, clinical staff, outside guests, and ancillary staff. Sessions were limited to 30 minutes to allow for succinct review and decrease interference with clinical workload. Sessions were recorded and available on a secure network for review at any time. Pre- and post-education surveys were recorded after every session.
Outcomes: Sessions have occurred on a weekly basis over the past 11 months. On average, staff feel that 50% of participants felt that they were able to identify gaps in their knowledge or skills. 60% felt that the topics were important to their work. 53% felt that the sessions were very effective. All sessions have been reviewed remotely. Eight clinical staff have presented topics and ten external presenters have participated.
Conclusion: Short regular educational sessions developed by clinical staff can be an effective way to further clinical skills and education in an accessible manner.