Purpose: This work exams the effect of nurse-driven, antihypertensive medication titration (AMT) standardized procedures (SP) on blood pressure (BP) control in patients with uncontrolled hypertension (HTN) at two ambulatory care health centers in a large, safety-net healthcare system in the United States (US). Participants will be able to identify key components of AMT SP’s and determine their impact on patients with uncontrolled HTN.
Description: Hypertension is a major contributor to cardiovascular disease. In 2017, almost half a million deaths in the country were a result of HTN. Nearly half of all adults in the US have HTN. Less than 25% of those with HTN have their BP at goal (CDC, 2019).
The organization worked to change the care approach for patients with HTN. The goal was to increase BP control and reduce the time to goal for these patients. The interdisciplinary practice committee, inclusive of nurses, providers, and leadership, developed AMT SPs, which guide RNs to obtain blood pressure measurements, evaluate medication adherence, and titrate antihypertensive medications remotely without patient-specific physician medication titration orders. HTN nurse-directed clinic (NDC) RNs received extensive training on HTN, the HTN NDC program, and SPs. Nurse practitioners proctored these RNs and checked them off on competency. Patients with uncontrolled HTN, meeting criteria, were referred to the NDC by their primary care provider, then screened by the RNs using the SP to determine appropriateness of the referral. If patients met criteria, they were enrolled into the program. Once patients met BP goal, they graduated from the program.
The following data was analyzed: number of patients referred to the program, patients enrolled, proportion of patients who graduated from the program, average number of patient visits to achieve BP goal, and average number of titrations needed to achieve BP goal.
Outcome: Over a 12-month period, 125 patients (81 [64.8%] center “A”; 44 [35.2%] Center “B”) were referred to the HTN NDC program. Of the 125 patients, 114 (91.2%) (75 [65.8%] center “A”; 39 [34.2%] center “B”) met criteria and were enrolled into the program. The proportion of enrolled center “A” patients who graduated from the program was .627 (n=47) compared to .667 (n=26) at center “B”. The average number of patient visits needed for patients to achieve BP goal was 2. The average number of medication titrations needed to reach BP goal was 1. These results demonstrate effectiveness of the HTN NDC program in helping patients reach BP goal, particularly when comparing the overall percentage (64%) of patients who met their BP goal to the national percentage of
Background: Communication and staff engagement are priorities in the healthcare setting. Our ambulatory care specialty clinic had grown over the past year, servicing 10,000 patients per year at 8 locations across the region. As our clinical service grew, we noted an opportunity to improve communication with our staff and providers on a daily basis.
Intervention tool, etc: We developed a template to organize daily staffing and census. This is displayed electronically and reviewed with a daily morning huddle. Team members who are off-campus call in to participate in the huddle. Staff are given opportunity to review areas for concern during the clinical day at all of our locations in one setting.
Outcomes: Since implementation of this model, we have seen our employee engagement scores improve drastically. Pediatric cardiology received the highest employee engagement scores in pediatrics (leader index 96/100). Our patient experience scores have remained elevated at 98-100%. Although these scores are multifactorial, we believe that the organizational foundation of the daily global huddle has had a significant factor in our clinical success.
Conclusion: A clinic morning huddle for a division with many locations is the single most effective meeting that a team can have.
Emory Saint Joseph's Hospital long-standing mission is to provide compassionate, clinically excellent healthcare in the spirit of loving service to those in need, with special attention to the poor and vulnerable. This fully supports the missional foundation of the Emory Healthcare System to deliver quality healthcare in a safe, patient- and family-centered environment. For that to happen, it is vital that ways are established to care for staff in the midst of unforeseen crisis, whether that be personal or work-related. Experience tells us that too often healthcare workers are guilty of forging through the work schedule without recognizing emotional or physical pain, signs of burnout, or obvious compassion fatigue. Recognizing this, we began to investigate the possibility of a Code Lavender team-support initiative.
Timing, which supports need, is vital to the success of a program. After this past year, it is clear that a program like Code Lavender is ncessary as we continue to navigate the journey of COVID-19 and its impact on our world. Resilience and support programs are often implemented within the inpatient setting, but the emotional impact of life and work can be equally as stressful within the ambulatory care setting and should also be addressed in order to allow healthcare workers to perform at their best and provide optimal care. As noted in the ANA Code of Ethics provision 5, section 5.2, we know that "nurses are professionals who assess, intervene, evaluate, protect, promote, advocate, educate, and conduct research for the health and safety of others and society." Unfortunately, we often forget that we are part of society's community.
Today I will help you see the purpose for the program as we explore the past experience with Code Lavender at our 410-bed acute-care facilty, and now as a test of change within several cardiology units of the ambulatory care setting. I will also share our shift in common paradigm, review national and local results based on review of evidence-based research and data summary, and provide options for support and implementation after discussion of clinically relevant and applicable scenarios.
Learning objectives
1) Understand the purpose of Code Lavender and how it benefits the patient by supporting the caregiver.
2) Identify best practices and strategies that might adequately compliment their area after assessing need.
3) Recognize the options for self-care and set standards for implementing this type of internal community support.
4) Share the process in initiating a culture of support and self-care for both the clinical and non-clinical staff.
Background/significance: Violence against nurses is prevalent across many healthcare settings, including emergency departments. Consequences of workplace violence include not only physical injury and damage to employee’s mental and emotional health, but also staff turnover. Factors contributing to violence may stem from individual factors, relationships, work environment, and organization. Many nurses feel that workplace violence is part of the job and thus assaults are under-reported.
Methods: Using data from a national nursing quality database, we examined the association between selected workplace environment items as reported by RNs and assaults on nursing personnel rates. The sample included 140 emergency services units in 140 U.S hospitals who submitted 2021 data on assaults on nursing personnel and nursing care hours, and whose RNs participated in a nurse survey in 2020 or 2021. Descriptive statistics were used to examine assaulted person and assailant characteristics. Correlations were used to explore relationships between total assault rate and RN-reported work context.
Results: Total assaults on nursing personnel per 10,000 nursing care hours in emergency services units ranged from 0 to 4.21. The mean rate was highest in emergency services units with 50,000 to 79,999 annual visits (0.72). Assaulted persons were female (70.56%), RNs (67.96%), hospital employee (97.96%), and injury level of none or minor (95.72%). Assailants were male (57.01%) patients (96.28%). Significant correlations were found with RN perception of quality of care and appropriate patient assignment as well as average number of activities RNs reporting leaving undone. No correlations were found with participation in hospital affairs nor nurse manager ability in leadership and support in emergency services units.
Conclusions/implications: Findings support previous research on assault characteristics. Barriers to reporting assaults on nursing personnel need to be addressed and eliminated. Once data is being monitored more consistently, healthcare entities can work to identify risk factors for workplace violence and develop prevention strategies which include target interventions aimed at broader cultural change and appropriate staffing resources.
Purpose statement: This quality improvement project was conducted to redesign the ongoing competency process to improve clinical educator satisfaction and increase leader involvement.
Background: The Donna Wright methodology of competency development and management has been a staple in our clinical education department since 2013. In 2019, clinical educators voiced concerns over the amount of time ongoing competency creation and validation was taking, without the support or understanding from the clinical leaders.
Practice change and implementation strategies: With a thorough analysis and environmental scanning, the competency process was reviewed and redesigned. A multidisciplinary workgroup used design thinking principles to focus on the processes for the clinical educator, and the importance of garnering buy-in and support from the end users and their clinical leaders. New processes included educational videos for clinical leaders highlighting steps in the competency process, standardized competency and validation statements, customizable rubrics, pre- and post-surveys, and workflow efficiencies in the use of the competency management system.
Evaluation: Outcomes of the competency process redesign were positive. 95% of clinical educators stated these new processes resulted in 1-50 hours of time saved and 89% evaluated the timeline as positive. 80% of clinical educators felt their opinions were heard. The perception of leader understanding of the competency process increased from 48% to 60%. Overall, the competency process was rated at a 4.45/5.
Conclusions and implications for practice: There are opportunities to continue to involve clinical leaders, streamline the sharing of materials between clinical educators, and document competency statements for entry into the competency management system. This project improved a process that had not been changed since implementation.
Outcome statement: The learner will utilize modern learning techniques to improve the quality of competency processes.
References
1) Durkin, G. J. (2019). Implementation and evaluation of wright’s competency model. Journal for Nurses in Professional Development, 35(6), 305–316. https://doi.org/10.1097/nnd.00...
2) Ostrander, K., Garrison, E., & Caruso, A. (2019). One hospital's experience with implementing On-Demand Annual competencies for nurses. Journal for Nurses in Professional Development, 35(1), 12–17. https://doi.org/10.1097/nnd.00...
3) SLHS Education. (2019). Brainstorming for Annual Competencies. YouTube. https://youtu.be/HvR4QH1MLxI.
4) Wright, D. (2005). The ultimate guide to competency assessment in healthcare (3rd ed.). Creative Health Care Management.
5) Wright, D. (2015). Competency assessment field guide: A real world guide for implementation and application. Creative health care management.
Traditional physician-centered healthcare settings are structured such that there are long wait times for appointments and complex approval processes. These structures hinder the provision of straight-forward medical care and intimidate those who are often marginalized due to financial, social, and racial factors. A well-written, well-implemented nurse-driven protocol has the potential to streamline processes, reduce redundancy, and hasten the provision of care. Culturally sensitive nurses are well positioned to provide care that is patient-centered and unbiased, further reducing barriers.
Robust nurse-driven protocols leverage nursing assessment and critical thinking while remaining within the scope of nursing practice, but they can be challenging to create. Nursing must collaborate with advanced providers, physicians, and leadership and orient the team to the protocol to ensure understanding, accurate implementation, and realistic expectations. The outcomes can be beneficial on multiple levels. The healthcare team gains mutual respect, and communication and collaboration is strengthened. Patient care is expedited and access to care is expanded.
Our urban clinic strives to reduce healthcare disparities among traditionally marginalized populations, including the LGBTQ+ community, recently incarcerated and/or homeless individuals, and the uninsured. The clinic is situated in a neighborhood where 80% of residents are of low socioeconomic status and the overwhelming majority are African-American and Latinx. Because they often have healthcare-related trauma, many have not accessed care in years and have complex unmet healthcare needs and they are at a higher risk of contracting HIV, STI, hepatitis C, and COVID-19.
The Future of Nursing 2020-2030 report calls for the nursing profession to take an active role in ensuring expanded access to “care that is safe, effective, person-centered, timely, efficient, and equitable.” Coupled with the strategic placement of our clinic, the development and implementation of nurse-driven protocols has had a major impact on opening access to timely and fiscally sound healthcare services. Because of the protocols, walk-in services are available for STI, HIV, and COVID-related screening, vaccination, and treatment. Low-barrier entrance for these services has led patients to engage further with healthcare at our clinic, as evidenced by repeat appointments and conversion to primary care. Specifically, we have experienced a three-fold increase in access to STI (sexually transmitted infection) services from April 2021 to October 2021 with a 20% conversion of high-risk individuals to PrEP (pre-exposure prophylaxis against HIV) therapy and a 22% conversion to primary care. When told “you are welcomed, the door is open,” people will seek services that lead to better health.
A review of the key elements in structuring an effective nurse-driven protocol will be shared, along with a blueprint for an effective protocol implementation plan. A quantitative and qualitative review of the positive outcomes of implementing such protocols on both the clinical team dynamics and the patients that interact with the healthcare team will be illustrated. After viewing the poster presentation, participants will be able to identify key elements of an effective nurse-driven protocol and develop an implementation plan to ensure successful adoption and compliance in their area of clinical care.
Purpose: Develop, implement, and evaluate an asynchronous web-based preceptor training that reinforces the scientific and ethical principles of nursing while further supporting the evolving role of the registered nurse in ambulatory care.
Description of project: As the demand for ambulatory care clinical sites increases in collegiate nursing programs, so does the need for accomplished nurse preceptors. Many nurses are clinical experts; however, they are novice educators and often struggle to effectively precept students during clinical rotations. Nurse preceptors working in ambulatory care settings are at an even more significant disadvantage when drawing upon personal experiences as preceptors because fewer clinical rotations are conducted in these settings as compared to acute care environments. Therefore, a needs assessment was completed, demonstrating the need for supplemental training to close the knowledge gap and improve the nurse’s experience as a preceptor.
Evidence has shown that a preceptorship model can strengthen the professional relationship between nurses and nursing students and enhance the student’s critical thinking and clinical judgment capabilities. In addition, using evidence-based teaching and learning methods supports the efficacy and objectives of the training.
An in-person preceptor training was created, implemented, and evaluated before the COVID-19 pandemic. However, the pandemic forced an end to in-person activities, and as a result, developing a web-based option became necessary. Considering a variety of training formats, our team selected one that would allow for an independent, self-paced, and engaging experience. Key topics included the history of preceptorship; adult learning theory; understanding the student nurse (diversity, learning styles, and challenges); preceptor benefits, traits, and strategies for success; and use of an evidence-based teaching method.
Desired outcomes: To determine the effectiveness of preceptor training, all participants will complete a post-training evaluation in order to determine if course objectives were met. Participants will also report their level of understanding and confidence performing in the role of a preceptor, their confidence in using the one-minute preceptor teaching method, and their satisfaction with the content and format of training.
Purpose: To improve efficiency and standardize evidenced-based recommendations to manage patients reporting suspected urinary tract infections by registered nurses utilizing approved NMG protocol in primary care
Problem and significance in nursing: Per Brusch (2020), “approximately 25-40% of women in the United States aged 20-40 years have had a UTI. UTIs account for over 6 million patient visits to physicians per year in the United States. Approximately 20% of those visits are to EDs.” Currently, primary care physicians at NMG primary and specialty care treat patients reporting symptoms of dysuria either by evaluation or referral to immediate care/another internal medicine provider or treat empirically with antibiotics. Appointment availability inhibits patient access to care, as well as delays in evaluation and treatment. Current practices also increase the risk of inappropriate prescription ordering, increasing the risk of antimicrobial resistance. The general public lack sufficient education regarding safe management, treatment, and prevention of urinary tract infections as well as other risks associated with their self-reported symptoms.
Currently, every patient reported symptom related to dysuria/urinary tract infection, primary care nurse clinicians fully triage at Northwestern Medical Group. Within scope, the nurses provide recommendations and await the physician evaluation, standardized recommendations, and treatment plans. Since 2011, there has been a standard for evaluation and treatment plan for patients with uncomplicated acute cystitis. With an approved standardized workflow, based from this recommendation, nurses are working at the top of their license, providing more efficient, safer care for patients and supporting physicians evaluating the patients and providing care more efficiently.
Design: Level IV – quality improvement
Transforming evidence and creating clinical policy to standardize safe management of patient reported urinary tract infections by registered nurses
Methods: Participants include primary care triage nurse clinicians within Northwestern Medical Group. With approval, education, and training on standardized policy, triage nurses will create nurse visits for clinical triage, approve diagnostic testing, and provide subjective and objective data for physician consultation. Physicians will create treatment plans related to patients reporting dysuria or self empirically diagnosed urinary tract infection, and nurses will be able to evaluate and expedite care coordination.
Planned analysis: Data will compare management of patient encounters in the electronic medical record from June 2019 to June 2021 to July 2021 to present related to dysuria:
• Occurrences aligned in care with standardized practice recommendations
• Number of touchpoints per patient encounter in the electronic medical record
• Measured time from patient report to evaluation and MD treatment
• Revenue lost related to care provided
Expected findings
• Standardized management of UTIs based on evidence-based recommendations
• Quicker response time to patients and symptom evaluation of suspected urinary tract infection
• Decreased empiric antibiotic ordering rates
• Lower risk of public antimicrobial resistance
• Positive impact on physician, nursing, and patient satisfaction
• Increased revenue and charge capture for physicians and NM system
Licensed practical nurses (LPNs) new to ambulatory care practice traditionally have not had robust programs for orientation, leaving a multifaceted gap in this rapidly growing area of practice. Unit-based orientation was left to managers. Many clinics have business managers, not nurse managers, creating a wider gap in LPN ambulatory care practice.
As a new vice president of ambulatory care nursing and director of education role was identified, allowing our organization to take a wider lens to evaluate our LPN transition- to-practice program. Literature was reviewed for strategies of successful existing programs. We found one LPN transition-to-practice program and talked with the designer. We discovered it was inpatient-focused with no ambulatory care component. Our original LPN transition-to-practice program evolved into a learning event for all ambulatory care nurses with poor attendance. We reviewed existing RN transition-to-practice program content, consulted managers, and successful ambulatory care LPNs to determine the needs of LPNs new to ambulatory care. The program was redesigned spring of 2020. LPNs are grouped into three-month cohorts after attending a one-day jumpstart class. We included our ambulatory care nursing leaders and NPD specialists as primary stakeholders in the review of quarterly education offerings. With their support, strategies to overcome attendance barriers included a virtual attendance option with learners completing pre-work in our learning management system prior to the live event. The virtual classroom reduces time away from direct patient care by eliminating travel and allowing attendance of all new LPNs from clinics in multiple locations. Another strategy was to present the ambulatory care LPN transition-to-practice program to all clinic managers with direct support from nursing executives. We encouraged leaders to created dedicated professional development time for the learners. Managers, in some cases, provided additional staff coverage for this time frame. Finally, the cohort design allows a dedicated ambulatory care nursing education specialist to lead quarterly classes building individual ambulatory care skills, competency, and relationships. To measure success of the program an evaluation was designed. The first evaluation is given after the jumpstart class and then repeated at 6- and 12-month intervals to measure competency and confidence of our new LPN staff. We have developed a dashboard to track retention of participants. The goal of the program is to increase competence, improve patient-centered care, and increase LPN satisfaction and retention.
Identification of professional practice gap:
Current state: A large academic medical center with a substantial ambulatory care nursing practice setting had a failed LPN transition-to-practice program.
Desired state: Redesign the LPN transition-to-practice program with updated content and increased attendance by gaining ambulatory care leader support.
Learning outcome: After this presentation, the learner will identify benefits of a robust LPN transition-to-practice program to aid a graduate practical nurse or new ambulatory care LPN by providing learning opportunities to build and improve competency in the care of the ambulatory care patient.
Patients need their healthcare team to provide timely access to care. An influencing factor of a patient’s perception of timely access to care is how their prescription refills are managed. What sounds like a relatively simple task can be burdensome for many reasons within busy ambulatory care practices, and chief among the challenges is overwhelming volume. In 2019, the primary care offices within a large multi-site ambulatory care practice group received over 500,000 prescription refill requests. Knowing that patient access was a top priority for the organization, the primary care team embarked on a journey to innovate and design a new way of work for prescription refill management, a staple, but ever-evolving patient need.
Strides have been made toward a team-based care model in the ambulatory care setting where each member of the patient care team works at the top of their scope and education level to ensure that patients receive high-quality and timely care. For this reason, the nurse plays an integral role in ambulatory care. By empowering these highly skilled clinicians to care for patients using approved prescription refill protocols, a significant volume of work was removed from physicians, and advanced practice providers and efficiencies were gained in the process. The increase in efficiency resulted in quicker turnaround for patients, fewer repeat calls by patients inquiring about their refill, and improved nurse confidence. As a result of this work, we expect to see additional improvements with patient education, patient satisfaction, and population health measures such as hypertension.
This presentation will focus on how a large multi-site ambulatory care practice group used the momentum of a reinvigorated patient access strategy and a newly hired director of ambulatory care nursing practice to empower front-line ambulatory care nurses in the redesign of the prescription refill process, not for their clinic, but a group of clinics, providing examples of:
• how the team approached the evaluation of current roles, responsibilities, and workflows of the four pilot practices
• the standardized workflow for prescription refill management utilizing the size and scale of the practice group; and
• the training and education plan developed by the nurses to ensure a smooth process across refill pools and provides a foundation for additional centralization efforts.
As a result of this pilot, the standardized process allowed for seamless floating between refill pools, a 20% reduction in the time a nurse spent on each message, allowing the nurse to complete more messages each day, less than 24-hour turnaround time for nurse responses to messages. Ultimately, efficiencies were found in the number of FTEs required to complete the work as well as the manner in which this work is completed. Amid a global pandemic, this was a win for our team members, and the invaluable lessons we have learned will change how we practice and lead well into the future.