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P092 - Digital Post-Discharge Outreach: A Value-Driven, Accessible Approach to Improving Care Transitions
Joan Slagle, DNP, RN, CNL
Tags: telehealth care coordination care transitions patient experience digital health

Updated: 07/02/24
Purpose: The purpose of instituting a digitized post-discharge outreach is to create a more efficient, consistent, patient-centric, and data-driven approach to care transitions. This transformative initiative addresses the critical aspects of post-discharge care, improves accessibility to a broader population, and captures valuable data to assess patient outcomes.

Description: Post-discharge outreach plays a crucial role in ensuring seamless care transitions, enhancing medication adherence, and providing early detection of medical complications after hospitalization. It empowers patients and caregivers by offering education and support, instilling confidence for self-managed care, and fostering trust in care teams. Additionally, it serves as a valuable data source for quality improvement and value-based care initiatives. In 2015, Stanford Health Care (SHC) introduced a centralized tele-triage call center, clinical advice services (CAS), aimed at enhancing patient connectivity and improving transitions of care. One of CAS’s core services includes outreach calls within 72 hours of discharge from the hospital or ED or following outpatient procedures. Patients are asked 9 questions related to their discharge instructions, pain control, follow-up appointments, home health services, and prescriptions. The initial call is handled by a non-licensed administrative specialist who escalates to a co-located registered nurse (RN) if clinical needs are identified. Standard work is utilized to resolve unmet needs.

Evaluation/outcome: From June 1, 2021, to July 30, 2022, SHC had 34,377 discharge encounters. Of these, 25,872 patients met the criteria for receiving a post-discharge call. Of the 25,872 patients, 10,943 were successfully reached by CAS within 24 hours of hospital discharge. While the calls helped identify patient needs, an analysis of the 10,943 patients found several opportunities for improvement. First, data revealed a reach rate of 42.3%, suggesting that not all patients were reachable by phone, potentially leaving gaps in follow-up care. Second, over half of the patients had an unmet need related to medications (19.6%), follow-up appointments (28.2%), or new/worsening symptoms (12.2%). Lastly, the existing process had no significant impact on reducing 30-day hospital readmissions.

To address these gaps, CAS initiated several enhancements to the post-discharge outreach process. First, CAS implemented a digital questionnaire focused on analysis’s top unmet needs: worsening symptoms, medications, and timely follow up with a healthcare provider. The digital questionnaire was launched on MyHealth, ensuring an accessible and user-friendly experience for patients and creating streamlined data collection for value-based care teams. The change from a manual phone call to an automated and interactive digital interface expands access to virtual points of care. In addition, the outreach exclusion criteria were updated to ensure CAS reached a broader and more representative pool of discharged patients in the community. The questionnaire engages with patients at risk for readmission by sending multiple touchpoints at 24 hours, 72 hours, 1 week, 2 weeks, and 3 weeks after discharge.

Conclusion: CAS plays a central role in ensuring seamless transitions from the hospital to home. The post-discharge outreach redesign reflects CAS’s commitment to providing exceptional patient care, furthering digital health efforts, and improving patient outcomes in a way that sets SHC apart in the healthcare industry.
P093 - Mock Codes in the Pediatric Ambulatory Care Setting
Emily Walenchok, MSN, RN
Tags: partnership pediatric emergency team building code

Updated: 07/02/24
Emergency medical events are historically a rare occurrence in the outpatient setting. However, as acuity and volume in outpatient pediatric clinics continues to rise, staff must be adequately prepared to respond to emergency events, perform life-saving interventions, and appropriately transition patients to a higher level of care. In hospital-based outpatient clinics, partnership with the inpatient code team is beneficial as it allows for efficient transition of care from medical assistants to code team caretakers. Developing the relationship between the team members within the two different settings is essential. A lack of education, knowledge, or communication can lead to poor outcomes for the patient and distress among staff members. Incorporating mock codes into the outpatient setting is an effective means to enhance hands-on and communication skills. The introduction of mock codes has allowed leadership to effectively identify learning needs, while also developing the nurse and medical assistant’s skill set. Pre-survey data showed that 74% of multidisciplinary staff, including techs, nurses, and medical assistants, felt uncomfortable in emergency medical situations. Many reported feeling uncomfortable in locating/using emergency medical equipment and the identification of their role during the emergency response. The initiation of mock codes following this survey has allowed for the development of staff’s skill set and confidence. This has also allowed for the identification of the need to bridge the gap between outpatient clinic staff and the code team responders. The outpatient setting differs significantly from the inpatient setting. Available resources, staff scope of practice, and the average acuity of the patient population creates the need for an altered response from clinic staff as well as the code team. Code team members are familiar with responding to the bedside for a patient who is already being cared for by a team of registered nurses. In the outpatient setting, code team members are met by a team of medical assistants whose scope of practice is more limited. Therefore, the code team must receive an efficient report and assume responsibility for medication administration, line placement, and decision-making. Building a partnership with the hospital code teams and ensuring medical assistant understanding of the importance of providing an effective patient report are therefore vital components to successful outcomes. Working to identify clear roles and expectations can lead to improved confidence, teamwork, and response. The introduction of mock codes in outpatient has helped to increase the effectivity and efficiency of staff response to emergency medical events while simultaneously improving the rapport between inpatient and outpatient staff. Post-survey data found that 94% of respondents felt positively regarding their ability to adequately respond to emergencies. Continuous evaluation of learning needs led to the creation of additional educational opportunities. Crash cart demonstrations, skill workshops, and enhanced mock code situations have allowed for continued development. The simulation experiences create a safe and controlled environment for staff to practice skills, ask questions, learn, and grow, while further improving patient care.
P094 - Comparison of Pre-Call Patient Intent to Telehealth Triage Nurse Recommended Disposition
Laurie O'Bryan, BSN
Tags: telephone triage access care access

Updated: 07/02/24
Background: Telehealth triage is the process of directing patients to the best and safest level of medical care (disposition) based upon the acuity and severity of their symptoms. The goal of telehealth triage is to get the patient the right care, at the right place, at the right time. The changing health care landscape offers greater patient access choices about where and when to seek medical care. Comparing the level of care patients are intending to seek to a telehealth triage recommended level of care is an important consideration when reviewing care access strategies. Comparative data can help drive optimal resource allocation (cost savings) as well potentially reduce care delays (patient safety).

Methods: Patients (including caregivers and parents) phoning a large academic medical center centralized telehealth triage team during a 9-month period of calendar years 2022 through 2023 were prompted to provide their pre-call intent by a service representative during their initial call intake and after the reason for call was captured. Patients were asked what level of care they intended to seek had they not called for telehealth triage support. The patients’ pre-call intent responses were grouped for purposes of analysis into four categories: call 911, seek urgent or emergent care, call or see doctor later, and self-care at home. The triage nurses used telehealth triage guidelines for decision support, and the triage nurses’ recommendations for level of care were similarly grouped into four disposition categories. Patient pre-call intent was compared to triage nurse recommendation.

Results: Pre-call intent was obtained for 7,504 encounters (73% adult, 27% pediatric) during the study period. 42 encounters were excluded because of missing data or inability to categorize patient intent or triager recommendation. Patients reported that they would have called 911 (2.1%), sought urgent or emergent care (38.1%), sought medical care later (32.1%), or treated themselves at home (27.7%). There was poor agreement (weighted Kappa 0.140) between the patients’ pre-call intent and the triage nurses’ level of care recommendations. For encounters, the triage nurses recommended a higher (more urgent) level of care (30.5%), a lower level of care (28.3%), or the same level of care (41.2%).

Conclusion: Poor agreement was found between patients’ pre-call intent and telehealth triage nurse recommended care. Triage nurses recommended either a higher or lower level of care in approximately 6 of 10 encounters. Encounters in which the triager recommended a higher level of care have the potential for facilitating earlier intervention, improving better medical care, and promoting patient safety. Encounters in which the triager recommended a lower level of care have the potential for reducing cost and optimizing use of limited healthcare resources.
P095 - Training and Utilizing Non-Licensed/Non-Certified Personnel to Combat Clinical Staff Shortages
James Ryan Taylor, MSN, RN, CPN, NE-BC
Tags: staffing shortages shortages unlicensed assistive technician

Updated: 07/02/24
Clinical staffing shortages in the ambulatory care setting are not going away anytime soon with conventional thinking in regard to clinical staff vacancies. The reason for this varies from not having enough students graduating to fill the needs to difficulty recruiting new graduates due to pay disparities between inpatient and outpatient nursing. To combat this, we have implemented a training program to advance receptionists and other non-licensed, non-certified assistive personnel to the role of technician to assist with tasks that do not require licensure or certification. The tasks include, but are not limited to, vital signs, height/weight, past medical history, EKG, and clearing non-triage phone messages. The purpose of this was to maximize our licensed and certified staff to work their true scope of practice by spending less time doing tasks that can be done by a technician. Technicians are also given the opportunity to complete certified clinical medical assistant (CCMA) training through the local college, which is fully supported by grants and hospital funding. This has created a pipeline of certified staff to fill vacancies while training them to the technician role in the process. The technician role is not used universally in the individual practices; however, there have been opportunities to utilize the technician in a dual receptionist/technician role when the technician-only role is not available at a particular practice. This allows the practices to have additional clinical support when there are call-ins, vacations, or just spikes in volume during the day without needing to request additional FTEs in their budget. After six months of this program, seven non-clinical staff have advanced to a CCMA role from the receptionist and technician roles. This has created an avenue for our non-clinical staff to learn additional skills and qualify for career advancement while meeting a growing need for clinical staff in the ambulatory care setting.
P096 - Using Timed Visual Reminders to Improve Pain Reassessment and Documentation
Jane Choi, MS, RN
Tags: pain reassessment visual reminders

Updated: 07/02/24
Problem/background: Pain is one of the primary reasons to seek medical care in the general population. Effective pain management is essential to facilitate the progression of a patient’s condition and recovery, shorten the length of hospital stay, promote quality of life, and reduce healthcare expenditures. In the fiscal year 2022, the completion of pain reassessment documentation was 38% at the current clinical site, a neuro intermediate care unit (neuro IMC) at a large tertiary care inner-city hospital. Published evidence shows that timed visual reminders in the electronic health record (EHR) and standardized staff education increase the frequency of timely pain reassessment.

Purpose/significance: The purpose of this DNP project is to improve the rate of pain reassessment and documentation within 60 minutes after PRN oral pain medication administration to 100% by using timed visual reminders within EPIC over 15 weeks in fall 2023 on the neuro IMC.

Methods: The planned intervention is to implement timed visual reminders in EPIC that pain reassessment must occur within 60 minutes after administration of oral pain medication. The staff RN logs in to the designated department in EPIC and selects the assigned patient. Timed visual reminders in EPIC automatically pop up after oral PRN pain medication administration. The project leader’s (PL) strategy to promote staff RN adherence includes obtaining formal written commitments from key partners for accountability, gaining staff buy-in by altered incentive structures, preparing champions to keep communication open with one-to-one meetings per request basis and shift huddles at 7 AM and 7 PM twice weekly to discuss project progress, sharing a summary of weekly chart audit data reports with staff and the nurse manager who is the project’s clinical service representative (CSR), and setting up online classes and in-person educational sessions during week one of the project. The PL conducts weekly chart audits to determine the frequency of pain reassessment and documentation within 60 minutes of post-PRN oral pain medication administration. The PL performs weekly chart audits and enters data (medical record number, completion of pain reassessment documentation within 60 minutes) into REDcap, a HIPAA-compliant database. The PL transforms these data into run charts to identify patterns and measure adherence over the 15 weeks. The PL performs a post-survey of staff RNs during week 15 regarding response to a visual reminder tool within EPIC.

Preliminary results: The project measures the number of times nurses completed pain reassessment within 60 minutes per total number of times nurses gave oral pain medications. During project weeks 1-6, RNs completed 352 oral pain medication administrations. 72% of RNs completed pain reassessment documentation within 60 minutes of administration of oral pain medication administration.

Preliminary conclusions: Three weeks of preliminary data indicate that timed visual reminders within EPIC improve pain reassessment and timeliness of documentation rate by at least 72%.
P097 - UAB Medicine CCMA Career Ladder
Antoinette Shedlarski, MSN, RN, CNL
Tags: career ladder

Updated: 07/02/24
Medical assistants (MA) have direct impact on the quality of care delivered to our patients. Increased competitive market wages make it more difficult to recruit and retain MAs, resulting in staffing gaps and high turnover which negatively affect all aspects of our care outcomes. Career ladders have been proven to provide opportunities for staff to learn new skills and gain added responsibilities which translate to improved compensation and job satisfaction. The proposed UAB Medicine CCMA ladder will augment our recruitment and retention efforts and provide a pipeline to build our foundational staff - growing them from novice to expert. Staff will have the option of pursuing a long-term career as a CCMA or working as a CCMA while pursuing a nursing degree. Each tier will have inclusion criteria, training/educational expectations, and minimum performance requirements (based on assigned tasks and defined job functions). Organizational investment of resources will be considered during compensation modeling. CCMA roles within the career ladder are focused on care coordination, EHR documentation, patient-centered care, and training and education.
P098 - Using an Academic-Practice Partnership to Develop a Telephone Triage Education Module
Ashley Roach, PhD, RN
Tags: primary care veteran academic-practice partnership undergraduate nursing

Updated: 07/02/24
Background/purpose: Telehealth is an important part of care delivery in the ambulatory care setting. One subset of telehealth is telephone triage. Telephone triage requires a specialized skillset to deliver safe care that is evidence based. Nurses who are new to the ambulatory care setting may not have the training and skill set to safely perform telephone triage. Also, undergraduate nursing students often lack exposure to concepts and content related to ambulatory care and telephone triage in their nursing programs. Academic-practice partnerships are collaborations between schools of nursing and practice settings that provide a mutual benefit to the practice setting and the school of nursing. The purpose of this presentation is to describe how school of nursing faculty and VA nurses in a veteran affairs nursing academic-practice partnership (VANAP) identified a knowledge gap in nurses and nursing students and collaborated to develop a telephone triage learning module to support the learning needs of new nurses as well as undergraduate nursing students.

Description: VANAP faculty recognized the need to better support undergraduate nursing students who had clinical placements in the ambulatory care setting, especially related to telephone triage. At the same time, VA nurses reported hiring nurses who were inexperienced in telephone triage. There was no formalized way to prepare nursing students or new nurse hires in skills such as telephone triage. VANAP faculty and VA nurses conducted a needs assessment to identify the most important concepts and content related to telephone triage. VANAP faculty and VA nurses met weekly to refine essential content that nurses would need to know to safely practice telephone triage.

Outcome: The training module will be used for new nurses hired into ambulatory care settings throughout the VA medical center as well as undergraduate nursing students in clinical rotations in ambulatory care settings at the VA. This presentation highlights the importance of collaboration between academic and practice settings to support students as well as nurses in ambulatory care practice. By leveraging the clinical expertise of the nurses and the educational expertise of faculty, a learning module was created to meet the needs of both new nurse hires and undergraduate nursing doing clinical rotations in the ambulatory care setting. Supporting new hires in their role and exposing undergraduate nursing students to primary care and equipping them with ambulatory care-specific skills can help prepare nurses and nursing students for successful careers in ambulatory care settings.
P099 - The Impact of the Nurse Manager Leadership Rounding: A Transformational Leadership Strategy on Nurse Retention Rate
Priya Nair, DNP, RN, CCCTM
Tags: intent to stay nurse retention turnover rate transformational leadership strategy

Updated: 07/02/24
Purpose: The purpose of the evidence-based practice project was to improve retention of experienced nurses within a large, urban academic hospital.

Description: A project team of two nurse managers formed to improve the retention rate of experienced nurses. Baseline turnover rate for nurses with greater than 1 year of experience at our tertiary academic medical center with two campuses was 17.5% at the downtown campus and 18.4% at the midtown campus. Using the Johns Hopkins nursing evidence-based practice model, we critically appraised 16 level III and V articles on retention strategies retrieved from Ovid MEDLINE and PubMed. Available evidence indicated that transformational leadership style from local nurse leaders is associated with low staff turnover and increased nurse satisfaction among experienced nurses. Our hospital promoted transformation leadership strategies, but resources were not standardized.

After receiving not human subjects research determination, the project team distributed standardized leadership rounding tools (e.g., preparation checklist, leadership rounding log, and spotlight report and communication resources) to managers and assistant nurse managers in the surgery division and ambulatory care divisions. Education and training on how to use the tools within current policies, processes, and structures were provided. Nurse leaders in these divisions completed rounding on their employees monthly. The project team served as a resource to leaders, with bi-weekly scheduled sessions to discuss implementation barriers, share best practices, and provide positive reinforcement and support. The project team built an electronic tracking dashboard and surveyed nurse leader perception of transformation leadership using the validated questionnaire on self-perception of nurses in exercising leadership before and after to monitor the impact of the project.

Outcome: 16 ambulatory care clinics and 7 inpatient units participated in the project, most at the downtown campus. Managers completed 158 employee rounds and 155 stoplight reports during the eight-week implementation period. After the implementation period, experienced nurse turnover rate decreased to 16.6% at downtown, but increased to 20.7% at midtown, which may reflect less unit participation. However, managers perception of how often they engaged in skills that are related to transformational leadership significantly increased (mean (SD) pre=43.9 (8.0) post=51.1 (3.5), p=0.011). Managers also voiced that the standardized transformational leadership tools and training helped to improve relationship building and trust, which are important characteristics of transformational leaders.
P100 - Triage in Maternal Fetal Medicine: Reducing Appointment Reschedules
Sara Gasner, BSN, RN
Tags: staffing patient experience inefficiencies multidisciplinary team

Updated: 07/02/24
Staff of maternal fetal medicine (MFM) identified inefficiencies in the scheduling processes causing unnecessary rework and inhibiting patient care. Many patient interventions and follow-up tests are dependent upon gestational parameters, making the timing of appointment critically important. Reschedules create rework and can decrease patient satisfaction. Creating efficiencies within today's staffing challenges is key to aid in both patient and staff satisfaction overall. A new process was identified and implemented with the goal to decrease appointment reschedules by 25%. Using the PDSA model for improvement, three interventions were selected and evaluated, while remaining FTE neutral. Those three interventions included creation of an appointment triage process, development of an MFM levels of care document and formation of a nurse triage calendar to promote closed loop communication with our multidisciplinary team. Post-intervention measures identified a 42% improvement. This project had a significant impact on patient satisfaction through improved access while simultaneously improving Nursing, Medical Administrative Assistant, and Patient Appointment Services Specialist team satisfaction through efficiencies gained.
P101 - Lifestyle Nursing – An Exciting New Field for Ambulatory Care Nurses
Author Eileen M. Esposito, DNP, RN, AMB-BC, DipACLM, CPHQ, Senior Healthcare Executive
Tags: patient engagement chronic disease top-of-license lifestyle nursing

Updated: 07/02/24
The US is an outlier when it comes to healthcare spending. According to the Commonwealth Fund, the US ranks 11th out of 11 industrialized countries studied in global healthcare system performance for four of the top five indicators, ranking in the top 2 for only one indicator care process. The US ranked last in access to care, equity, healthcare outcomes, and administrative efficiency. The US ranks highest in healthcare spending (17.9% GDP) and lowest in health system performance. Of the 11 countries reviewed, the US has the highest number of people with chronic disease; 60% of US adults has one chronic disease and 40% have two or more chronic diseases and spends on average over $12,500 per capita. The global average is $6,414 per capita. Clearly, the US approach to patient chronic disease management can be improved. For the last 20 years a new, evidence-based science has been taking root. This science, know as l00ifestyle medicine, takes a root cause approach to chronic disease instead of a symptom-based treatment approach. It is particularly effective in stabilizing or reversing heart disease and diabetes. A large-scale study revealed 58% of people with prediabetes did not progress to diabetes after a 16-week program of education on lifestyle factors impacting diabetes.

Lifestyle medicine is a holistic approach to improving health and reducing the impacts of chronic diseases such as diabetes, heart disease, and hypertension. Lifestyle medicine uses simple but very powerful lifestyle changes to prevent many of the most common chronic diseases and has been observed to halt or reverse their progression. The tenets of lifestyle medicine are focused on six pillars: eating whole, mostly plant-based foods; increasing physical activity; achieving restorative sleep; managing stress; maintaining social connections; and avoiding risky substances such as tobacco and alcohol. Lifestyle medicine relies on a partnership between the healthcare team and the patient. In this partnership, the lifestyle nurse guides the patient, provides expert knowledge, and encourages self-decision making. The patient is viewed as an expert in their life experiences and when health goals are based on the patient’s beliefs, preferences, and values, the patient is more likely to achieve those goals. Patient engagement is a nurse-sensitive indicator and nurses are adept at using patient engagement techniques such as motivational interviewing to elicit patient-determined goals for health. Using coaching methods nurses can engage patients in their healthcare goals and can monitor and support them in achieving these goals over time.

Lifestyle nursing uses a back-to-basics approach and evidence-based science to move patients from a state of illness to a state of wellness. Lifestyle nursing relies on top-of-license critical thinking and nursing modalities to improve patient outcomes. As a result of nursing collaboration with the patient and the primary care provider, many patients are able to reduce or discontinue medication. Lifestyle nursing is consistent with Pender’s theory of health promotion, which focuses on increasing a person’s well-being consistent with health as a positive, dynamic state and not merely the absence of disease.
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