Melanie Archer, MSN, RN | Laura Coyle, DNP, RN, CNL, CPHQ, CLSSBB | Jamie Falk, MS, RN-BSN, CNML | Patricia Goodnite, MSN, RN, NI-BC | Katie O'Grady, MSN, RN-NE | Falissa Prout, MSN, NI-BC, NEA-BC | Traci Solt, DNP, NEA-BC, FACHE, AMC-BC, CCM, CRRN, Director for Clinical Services, VHA National Office of Primary Care
Updated: 03/07/24
Evidence-based practice: In FY2021, the Veterans Health Administration (VHA) national compliance rate with the patient-aligned care team (PACT) compass measure two-day post-discharge contact was 61.82%, well below the national benchmark of 75%. Assessed national performance measures and identified strong practices within top performers enterprise wide. Identified variability in two-day post-discharge processes and documentation throughout the VHA. Conducted literature review and applied the Agency for Healthcare Research and Quality Re-Engineered Discharge (RED) toolkit to create national standardized documentation template.
Purpose: An enterprise-wide lean six sigma improvement project workgroup developed an evidence-based standardized post discharge template for primary care nurses. Goal to reduce unnecessary utilization of acute care resources through utilization of evidence-based two-day post-discharge contact utilizing a national standardized documentation template approved by national nursing leadership council. “Readmission following an acute care hospitalization is a costly and often preventable event” (Horwitz et al., 2011, p.7). Poor coordination between settings is associated with poor health outcomes and increased health care utilization and cost. Post-discharge visits can smooth care transitions. Connecting with veterans within two days of hospital discharge affords the opportunity to answer questions, clarify medication regimens, and review appointments.
Description: The two-day post-discharge PI project has been a 1.5-year collaborative project with multiple stakeholders that include Office of Nursing Service (ONS), Office of Nursing Informatics (ONI), Office of Primary Care (OPC), human factor engineering (NFE), front line PACT RNs and LPNs which was coordinated by OPC.
Development: environmental Scan for existing templates, review of the evidence, human factor engineering-heuristic evaluation
Pilot: 6 sites: 1) Hines (VISN 12), 2) Gulf Coast Veterans Health Care System (Biloxi, MS) (VISN 16), 3) Central Iowa (VISN 23), 4) Pittsburg Integrated site (VISN), 5) Asheville, NC (VISN 6). As of 6/2023 template was utilized over 7000 times. Over 75 health factors, seven updates made to the piloted template
Go-live June 2023: training-primary care leaders, pact team members, clinical application coordinators (CACs), template released June 15,2023; training delivered June 20-30, 2023
Evaluation/outcome: pre-pilot two-day post-discharge contact: 62.93%; post-pilot two-day post-discharge contact: 66.392%; continue to track update data post-national go-live to report and share if selected
HRO alignment: leadership commitment; focused on improving an inpatient-based measure through utilization of resources from outpatient services. Culture of safety; focused on preventing harm by proactively reaching out to veterans who have been recently discharged. Continuous process improvement: applying lean methodology and evidence-based practice to create high reliability through standardized process.
Deference with expertise: conducted human factor analysis and involved the front-line PC PACT RNs and LPNs, clinical application coordinators from local facilities, along with national leadership from ONS/ONI and OPC.
Purpose: An enterprise-wide lean six sigma improvement project workgroup developed an evidence-based standardized post discharge template for primary care nurses. Goal to reduce unnecessary utilization of acute care resources through utilization of evidence-based two-day post-discharge contact utilizing a national standardized documentation template approved by national nursing leadership council. “Readmission following an acute care hospitalization is a costly and often preventable event” (Horwitz et al., 2011, p.7). Poor coordination between settings is associated with poor health outcomes and increased health care utilization and cost. Post-discharge visits can smooth care transitions. Connecting with veterans within two days of hospital discharge affords the opportunity to answer questions, clarify medication regimens, and review appointments.
Description: The two-day post-discharge PI project has been a 1.5-year collaborative project with multiple stakeholders that include Office of Nursing Service (ONS), Office of Nursing Informatics (ONI), Office of Primary Care (OPC), human factor engineering (NFE), front line PACT RNs and LPNs which was coordinated by OPC.
Development: environmental Scan for existing templates, review of the evidence, human factor engineering-heuristic evaluation
Pilot: 6 sites: 1) Hines (VISN 12), 2) Gulf Coast Veterans Health Care System (Biloxi, MS) (VISN 16), 3) Central Iowa (VISN 23), 4) Pittsburg Integrated site (VISN), 5) Asheville, NC (VISN 6). As of 6/2023 template was utilized over 7000 times. Over 75 health factors, seven updates made to the piloted template
Go-live June 2023: training-primary care leaders, pact team members, clinical application coordinators (CACs), template released June 15,2023; training delivered June 20-30, 2023
Evaluation/outcome: pre-pilot two-day post-discharge contact: 62.93%; post-pilot two-day post-discharge contact: 66.392%; continue to track update data post-national go-live to report and share if selected
HRO alignment: leadership commitment; focused on improving an inpatient-based measure through utilization of resources from outpatient services. Culture of safety; focused on preventing harm by proactively reaching out to veterans who have been recently discharged. Continuous process improvement: applying lean methodology and evidence-based practice to create high reliability through standardized process.
Deference with expertise: conducted human factor analysis and involved the front-line PC PACT RNs and LPNs, clinical application coordinators from local facilities, along with national leadership from ONS/ONI and OPC.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Objective: Identify programs that improve patient outcomes and reduce utilization.
Purpose: Healthcare changing from fee-for-service to value-based reimbursement models requires care redesign. The health system tasked a nurse practitioner to implement and scale evidence-based, population health programs across the entire health system to improve quality of care and patient outcomes.
Relevance/significance (why): With more than 80% of a person's health outcomes affected by social determinants of health, patient care requires a switch in focus from traditional “clinical care” to a focus on social, economic, and environmental factors. Asynchronous care focused on patient-centered interventions has the potential to improve access to preventive services and positively impact chronic disease outcomes. This shift in care delivery can also reduce resource utilization and lower overall healthcare costs.
Strategy/implementation/methods: Due to the success of a nurse-led, clinic-level population health program, the nurse practitioner was named director of population health and tasked with improving patient outcomes and quality of care across the health system by implementing evidenced-based population health programs. These centralized programs are nurse-led, team-based, and interprofessional in nature and were initiated in individual clinics and then scaled across the health system. The population health programs include transitions of care management (TCM), chronic care management (CCM), community health workers (CHW), social work, eldercare navigation, and a quality program that works collaboratively with patients and payers.
Evaluation/outcomes/results: The population health program is now 30 employees strong and spans inpatient, outpatient, and partners with community-based organizations. The CCM program has enrolled 202 patients. TCM cares for 250 patients monthly; the social care program cares for 150 patients monthly, and the quality program averages care gap work for 3,500 patients monthly. Colorectal cancer screening targeted outreach resulted in 238 patient contacts with 102 external records requested and 21 screenings ordered. Outreach for targeted patients showed a 49% and a 7.6% reduction in readmissions in these patient populations. Systemwide, readmission rates decreased by 2.08%.
Conclusions/implications: The nurse-led, asynchronous population health programs improved outcomes and reduced utilization. Nurses have an opportunity to reshape the delivery system to provide efficient and effective care that addresses upstream barriers to provide care in the least restrictive and least expensive manner.
Purpose: Healthcare changing from fee-for-service to value-based reimbursement models requires care redesign. The health system tasked a nurse practitioner to implement and scale evidence-based, population health programs across the entire health system to improve quality of care and patient outcomes.
Relevance/significance (why): With more than 80% of a person's health outcomes affected by social determinants of health, patient care requires a switch in focus from traditional “clinical care” to a focus on social, economic, and environmental factors. Asynchronous care focused on patient-centered interventions has the potential to improve access to preventive services and positively impact chronic disease outcomes. This shift in care delivery can also reduce resource utilization and lower overall healthcare costs.
Strategy/implementation/methods: Due to the success of a nurse-led, clinic-level population health program, the nurse practitioner was named director of population health and tasked with improving patient outcomes and quality of care across the health system by implementing evidenced-based population health programs. These centralized programs are nurse-led, team-based, and interprofessional in nature and were initiated in individual clinics and then scaled across the health system. The population health programs include transitions of care management (TCM), chronic care management (CCM), community health workers (CHW), social work, eldercare navigation, and a quality program that works collaboratively with patients and payers.
Evaluation/outcomes/results: The population health program is now 30 employees strong and spans inpatient, outpatient, and partners with community-based organizations. The CCM program has enrolled 202 patients. TCM cares for 250 patients monthly; the social care program cares for 150 patients monthly, and the quality program averages care gap work for 3,500 patients monthly. Colorectal cancer screening targeted outreach resulted in 238 patient contacts with 102 external records requested and 21 screenings ordered. Outreach for targeted patients showed a 49% and a 7.6% reduction in readmissions in these patient populations. Systemwide, readmission rates decreased by 2.08%.
Conclusions/implications: The nurse-led, asynchronous population health programs improved outcomes and reduced utilization. Nurses have an opportunity to reshape the delivery system to provide efficient and effective care that addresses upstream barriers to provide care in the least restrictive and least expensive manner.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Tags:
emergency department ED
fallfall injuries
multicomponent fall prevention programs MFPP
kinder fall risk assessment tool KINDER1
Updated: 03/07/24
There are limited studies regarding falls and fall injuries specific to the emergency department. The emergency department (ED) is a unique environment with a complex/diverse patient population and extrinsic factors that raise the risk of patient falls and fall injuries.
PICOT question: In the adult emergency department (ED) patient population, would utilizing the Kinder fall risk assessment tool (KINDER1), as compared to the current fall risk assessment, lead to a decrease in falls and fall injuries four months post-implementation? The purpose of this project was to assess ED patients for fall risk with KINDER1 to initiate patient-specific multicomponent fall prevention programs (MFPP) to reduce patient falls and fall injuries.
A fall committee was organized that included nursing leadership, ED nurses, and support staff who decided to adopt the KINDER1 at the time of the triage process. This committee used the plan-do-check-act cycle for this quality improvement project to identify and implement patient-specific MFPP for patients with fall risk at the point of ED triage. Education was provided to the nurses and support staff to identify and implement KINDER1. With the correct MFPP in place, patient falls should either be preventable or simply should not occur. It focuses on four simple questions: presented to ED because of falls, age >70, altered mental status, impaired mobility, and nursing judgment. Data on patient fall and fall injury were collected retrospectively before and after the project implementation. After implementing the KINDER1, the compliance rate was monitored by random chart audits and staff compliance with fall risk assessment at the point of ED triage for four months.
The compliance rate increased as staff became more knowledgeable about the new KINDER1. Fall risk identification compliance increased from 73% to 88%. MFPP initiation compliance improved from 57% to 91%. Bed alarm usage compliance rate improved from 10% to 53%. The number of fall/fall injuries rate decreased from 0.15/0.06 in December 2020 to 0.08/0 in April 2021.
The learning objective for this project will be to reduce falls and fall injuries for the complex and diverse patient population in the emergency department, identify the high fall risk and develop patient-specific MFPP and increase interprofessional education compliance to reduce falls and fall injuries.
PICOT question: In the adult emergency department (ED) patient population, would utilizing the Kinder fall risk assessment tool (KINDER1), as compared to the current fall risk assessment, lead to a decrease in falls and fall injuries four months post-implementation? The purpose of this project was to assess ED patients for fall risk with KINDER1 to initiate patient-specific multicomponent fall prevention programs (MFPP) to reduce patient falls and fall injuries.
A fall committee was organized that included nursing leadership, ED nurses, and support staff who decided to adopt the KINDER1 at the time of the triage process. This committee used the plan-do-check-act cycle for this quality improvement project to identify and implement patient-specific MFPP for patients with fall risk at the point of ED triage. Education was provided to the nurses and support staff to identify and implement KINDER1. With the correct MFPP in place, patient falls should either be preventable or simply should not occur. It focuses on four simple questions: presented to ED because of falls, age >70, altered mental status, impaired mobility, and nursing judgment. Data on patient fall and fall injury were collected retrospectively before and after the project implementation. After implementing the KINDER1, the compliance rate was monitored by random chart audits and staff compliance with fall risk assessment at the point of ED triage for four months.
The compliance rate increased as staff became more knowledgeable about the new KINDER1. Fall risk identification compliance increased from 73% to 88%. MFPP initiation compliance improved from 57% to 91%. Bed alarm usage compliance rate improved from 10% to 53%. The number of fall/fall injuries rate decreased from 0.15/0.06 in December 2020 to 0.08/0 in April 2021.
The learning objective for this project will be to reduce falls and fall injuries for the complex and diverse patient population in the emergency department, identify the high fall risk and develop patient-specific MFPP and increase interprofessional education compliance to reduce falls and fall injuries.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/21/24
Updated: 03/21/24
Learning objective: Evaluate the use of an oncology urgent care clinic to reduce emergency department (ED) utilization and readmission rates (RAR) for cancer patients.
Purpose: The purpose of this quality improvement project is to examine the impact of a cancer acute treatment (CAT) clinic for meeting the urgent health needs of cancer patients.
Description: About 15 million Americans suffer from cancer, accounting for 4.5 million ED visits annually. Aside from an ED encounter, same-day care for oncology patients was limited at our facility. An oncology urgent care clinic can reduce ED visits and lower healthcare costs for patients and facilities. Oncology costs represent a large and growing burden for the US healthcare system, with acute care hospitalization as one of the single largest drivers of overall cost. Increasing the number of oncology patients with urgent health problems who are treated in an ambulatory care setting is a priority of our cancer center. In October 2022 we opened a CAT clinic (staffed by an advance practice provider) as a pilot project within our oncology infusion center. This allowed patients who were experiencing acute issues to receive phone triage, and if appropriate, come in to be seen by a provider the same day.
Methods: We examined the following: 30-day unplanned readmission rates (RAR) for the business quarter prior to CAT implementation (RAR-Pre) and for 3 quarters after implementation (Q1; Q2; Q3); number of patients treated in the CAT clinic and discharged home versus being sent to the ED or admitted in Q1-3; top three infection diagnoses, labs, and medications ordered during CAT clinic encounters; and cost of CAT clinic encounters by dividing the total cost of all encounters over 12 months by the total number of patients seen during that time.
Evaluation/outcome: RAR-Pre for our patient population was 12.1%. CAT clinic implementation reduced RAR over Q1-Q3 to 11.1-11.9%. About 91% of CAT clinic patients were able to be treated in an outpatient setting and discharged home instead of being sent to the ED or being admitted (Q1: 91.6%; Q2: 93.75%; Q3: 87.5%; Mean = 90.95%). The average operational cost of an encounter in the CAT clinic was $347.64. The top three infection diagnoses seen included: COVID-19 rule out (30.9%), gastrointestinal infections (21.1%), and C. difficile (20.3%). The most frequently ordered labs were CBC/diff (77.2%), BMP (76.4%) and urinalysis/urine culture (24.4%). The most common types of medications ordered included intravenous fluids (53.7%), anti-emetics (22.8%), and electrolytes (16.3%). The CAT clinic has now been expanded after successfully reducing ED utilization and hospital readmissions for oncology patients.
Purpose: The purpose of this quality improvement project is to examine the impact of a cancer acute treatment (CAT) clinic for meeting the urgent health needs of cancer patients.
Description: About 15 million Americans suffer from cancer, accounting for 4.5 million ED visits annually. Aside from an ED encounter, same-day care for oncology patients was limited at our facility. An oncology urgent care clinic can reduce ED visits and lower healthcare costs for patients and facilities. Oncology costs represent a large and growing burden for the US healthcare system, with acute care hospitalization as one of the single largest drivers of overall cost. Increasing the number of oncology patients with urgent health problems who are treated in an ambulatory care setting is a priority of our cancer center. In October 2022 we opened a CAT clinic (staffed by an advance practice provider) as a pilot project within our oncology infusion center. This allowed patients who were experiencing acute issues to receive phone triage, and if appropriate, come in to be seen by a provider the same day.
Methods: We examined the following: 30-day unplanned readmission rates (RAR) for the business quarter prior to CAT implementation (RAR-Pre) and for 3 quarters after implementation (Q1; Q2; Q3); number of patients treated in the CAT clinic and discharged home versus being sent to the ED or admitted in Q1-3; top three infection diagnoses, labs, and medications ordered during CAT clinic encounters; and cost of CAT clinic encounters by dividing the total cost of all encounters over 12 months by the total number of patients seen during that time.
Evaluation/outcome: RAR-Pre for our patient population was 12.1%. CAT clinic implementation reduced RAR over Q1-Q3 to 11.1-11.9%. About 91% of CAT clinic patients were able to be treated in an outpatient setting and discharged home instead of being sent to the ED or being admitted (Q1: 91.6%; Q2: 93.75%; Q3: 87.5%; Mean = 90.95%). The average operational cost of an encounter in the CAT clinic was $347.64. The top three infection diagnoses seen included: COVID-19 rule out (30.9%), gastrointestinal infections (21.1%), and C. difficile (20.3%). The most frequently ordered labs were CBC/diff (77.2%), BMP (76.4%) and urinalysis/urine culture (24.4%). The most common types of medications ordered included intravenous fluids (53.7%), anti-emetics (22.8%), and electrolytes (16.3%). The CAT clinic has now been expanded after successfully reducing ED utilization and hospital readmissions for oncology patients.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Learning objective/purpose: The evolution of clinical decision support tools (CDSTs) has guided the proliferation of these tools within the healthcare landscape. These multiple tools are critical for telephone triage, as they provide guidance on the appropriate level of care, potentially reducing healthcare costs. Despite these advances to improve the quality of care, research suggests these tools may exacerbate health disparities among already marginalized populations. This evidence-based project delves into and discusses algorithmic bias within CDSTs. It addresses biases related to the skin assessment during the telephone triage process when utilizing CDSTs. Through this educational activity, participants will gain an understanding of how biases embedded in CDSTs can adversely impact disparities for darkly pigmented patients and learn about interventions implemented to mitigate these biases.
Description: Health disparities related to skin assessment biases woven into CDSTs are a complex and sensitive topic that can impact patients with darkly pigmented skin. The biases embedded into CDSTs primarily stem from the development of algorithms utilizing data that focuses on patients with lightly pigmented skin, and a lack of diverse interdisciplinary teams to help shape and develop these tools. Research affirms that normative descriptive words such as red, blue, pink, blanch, or pale during the skin assessment of darkly pigmented patients results in inappropriate diagnoses leading to poorer health outcomes. To address biases in CDSTs that contribute to health disparities, best practices support interventions incorporating comprehensive and inclusive language into clinician education and CDSTs related to the skin assessment of darkly pigmented patients.
Evaluation/outcome: A preliminary evaluation of nursing staff was completed to assess their knowledge on the differences of skin color changes in various patient populations and their comfortability related to this sensitive topic. Of 35 RN respondents, results revealed approximately 20% of nurses felt neutral to extremely uncomfortable asking additional questions pertaining to skin color.
The telephone triage CDST was evaluated for algorithm bias in skin assessment, which uncovered notable variations for the recommended dispositions based on positive and negative responses to questions related to skin color changes. Differences with the recommended level of care ranged from “911 NOW” for the positive response to skin color changes, referring to “blue color around lips,” compared to “within 24 hours” for a negative response.
Staff underwent training in inclusive skin assessment including images to aid in knowledge. In the post-education survey, 100% of respondents expressed intent to apply the knowledge gained and expressed confidence that it would improve their ability to assess patients more accurately. Furthermore, an interdisciplinary team is assessing modifications to the CDST, aiming to incorporate inclusive language and resources into the tool.
Description: Health disparities related to skin assessment biases woven into CDSTs are a complex and sensitive topic that can impact patients with darkly pigmented skin. The biases embedded into CDSTs primarily stem from the development of algorithms utilizing data that focuses on patients with lightly pigmented skin, and a lack of diverse interdisciplinary teams to help shape and develop these tools. Research affirms that normative descriptive words such as red, blue, pink, blanch, or pale during the skin assessment of darkly pigmented patients results in inappropriate diagnoses leading to poorer health outcomes. To address biases in CDSTs that contribute to health disparities, best practices support interventions incorporating comprehensive and inclusive language into clinician education and CDSTs related to the skin assessment of darkly pigmented patients.
Evaluation/outcome: A preliminary evaluation of nursing staff was completed to assess their knowledge on the differences of skin color changes in various patient populations and their comfortability related to this sensitive topic. Of 35 RN respondents, results revealed approximately 20% of nurses felt neutral to extremely uncomfortable asking additional questions pertaining to skin color.
The telephone triage CDST was evaluated for algorithm bias in skin assessment, which uncovered notable variations for the recommended dispositions based on positive and negative responses to questions related to skin color changes. Differences with the recommended level of care ranged from “911 NOW” for the positive response to skin color changes, referring to “blue color around lips,” compared to “within 24 hours” for a negative response.
Staff underwent training in inclusive skin assessment including images to aid in knowledge. In the post-education survey, 100% of respondents expressed intent to apply the knowledge gained and expressed confidence that it would improve their ability to assess patients more accurately. Furthermore, an interdisciplinary team is assessing modifications to the CDST, aiming to incorporate inclusive language and resources into the tool.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
The Institute for Medicine set a goal that 90% of healthcare decisions were evidence-based by 2024. As an industry, we need to meet this goal. Nurses account for the largest group of healthcare providers with direct patient access and managerial support of care initiatives. The gap between what nurses know and what they do can have life-altering consequences. The degree to which nurses base their practice behaviors on research, EBP competence, and use of EBP skills is sub-optimal and is directly influenced by organization and institutional barriers. Common barriers to implementing EPB behavior change include organizational culture, leadership, networks and communication, resources, evaluation, monitoring and feedback, and EBP mentors/champions. Some sub-features included resources that support collaboration, teamwork, communication, financial support, timing/staffing workload, EBP education, and training. Supporting organizational initiatives and leadership development can strengthen the cultural advancement of EBP5.
Supporting the development of EBP skills in an ambulatory care setting can be challenging. Our facility has 300 nurses in more than five facilities spanning five counties. In ambulatory care settings, fewer nurses are in one area than in inpatient settings. Nurses in ambulatory care settings become siloed in their specialty, resulting in variable practice delivery, even within the same setting. Ambulatory care nurses find additional challenges in participating in projects and meetings. Shortened/frequent workdays (compared to inpatient settings), limited free time during the day, tight clinic schedules, and lack of role coverage can prevent participation in hospital-wide meetings that often happen when the clinic is busiest. The EBP specialist role, in the form of leadership support, has enhanced the development of EBP competence in ambulatory care nursing.
Intervention: Leadership development and resource availability to ambulatory care nursing was a priority for the evidence-based practice specialist role. The EBP specialist role supported the development of the ambulatory care EBP council, stimulated individual nursing participation, provided a direct point of contact for support/services, integrated membership in various ambulatory care committees and leadership groups, and developed interaction with various councils (outpatient clinical council, ambulatory care RN leadership committee, professional governance nursing, and transition councils). Increased visibility of the EBP specialist role has allowed ambulatory care RNs increased opportunities to receive EBP-specific education, resources, podium/poster development support, project discussions, and opportunities to network and collaborate outside their clinic setting.
Outcomes: In the first six months of the EBP specialist role, ambulatory care nursing submitted at least six podium presentations and three poster submissions for at least four 2024 conference calls for abstracts. Ambulatory care nurses are more aware of local opportunities and are interested in participating in events. In addition, two ambulatory care registered nurses have published in peer-reviewed journals and a poster at a national conference and are participating in an EBP fellowship through a local university cohort. The outpatient clinic council participation has grown by 28% in the past year. The ambulatory care EBP council has consistently had meetings in 2023 (previously, in 2022, we did not have consistent interest) with 13 members (140% growth), a chair and co-chair with an active agenda, and multiple projects in development.
Supporting the development of EBP skills in an ambulatory care setting can be challenging. Our facility has 300 nurses in more than five facilities spanning five counties. In ambulatory care settings, fewer nurses are in one area than in inpatient settings. Nurses in ambulatory care settings become siloed in their specialty, resulting in variable practice delivery, even within the same setting. Ambulatory care nurses find additional challenges in participating in projects and meetings. Shortened/frequent workdays (compared to inpatient settings), limited free time during the day, tight clinic schedules, and lack of role coverage can prevent participation in hospital-wide meetings that often happen when the clinic is busiest. The EBP specialist role, in the form of leadership support, has enhanced the development of EBP competence in ambulatory care nursing.
Intervention: Leadership development and resource availability to ambulatory care nursing was a priority for the evidence-based practice specialist role. The EBP specialist role supported the development of the ambulatory care EBP council, stimulated individual nursing participation, provided a direct point of contact for support/services, integrated membership in various ambulatory care committees and leadership groups, and developed interaction with various councils (outpatient clinical council, ambulatory care RN leadership committee, professional governance nursing, and transition councils). Increased visibility of the EBP specialist role has allowed ambulatory care RNs increased opportunities to receive EBP-specific education, resources, podium/poster development support, project discussions, and opportunities to network and collaborate outside their clinic setting.
Outcomes: In the first six months of the EBP specialist role, ambulatory care nursing submitted at least six podium presentations and three poster submissions for at least four 2024 conference calls for abstracts. Ambulatory care nurses are more aware of local opportunities and are interested in participating in events. In addition, two ambulatory care registered nurses have published in peer-reviewed journals and a poster at a national conference and are participating in an EBP fellowship through a local university cohort. The outpatient clinic council participation has grown by 28% in the past year. The ambulatory care EBP council has consistently had meetings in 2023 (previously, in 2022, we did not have consistent interest) with 13 members (140% growth), a chair and co-chair with an active agenda, and multiple projects in development.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Background: Pediatric patients account for 26.8 million emergency department (ED) visits annually, costing an estimated 7.8 billion dollars. The otolaryngology (ENT) clinic identified 179 ED visits in 2022 and 130 ED visits in 2021 within 30 days of tonsillectomy. Extensive post-op education is provided during clinic visits, although retention remains variable, contributing to preventable ED visits.
Purpose: To utilize a text messaging program, Tonsil Texts, to decrease ED visits after tonsillectomy, provide support and education to caregivers, and provide access to contact ENT with concerns.
Methodology: This quality improvement project was one implementation strategy in a larger health literacy initiative. Staff conducted a root cause analysis and created a key driver diagram to identify barriers. Two barriers to caregiver retention of information were identified, including delay between visit and surgery and the amount of information provided. To address these barriers, Tonsil Texts were initiated. Systemwide analytics built a report including all patients undergoing tonsillectomy, which communicated with PatientEXP software to send automated text messaging in English or Spanish. All patients were enrolled beginning December 2022, but could opt-out. Families received post-op video instructions on the child's surgery date, providing time to watch while their child was in the operating room. Additional messages were sent on post-op days 2, 4, and 7 with reinforcement of care and encouragement. All messaging included a hyperlink to the patient portal and the clinic phone number. A survey was sent on day 14, indicating the end of standard messaging and post-op period, and requesting feedback on program timeline and messaging.
Results: Our ENT surgeons have completed 729 tonsillectomies in 2023, with 80 patients returning to the ED within 30 days (10.97%). This shows trending improvement from 2022 where 13.7% of patients returned (n=1299), and 2021 where 13.4% returned (n=967). As of June 2023, 96.15% of caregivers found Tonsil Texts helped to manage their child’s pain after surgery (n=78). 98.72% found the Tonsil Texts information was useful and delivered on the appropriate days and times. 97.44% indicated that the messaging helped them know who to contact for concerns. Caregivers reported positive feedback suggesting the texts "helped [her daughter] cope," were received "right on time," and came through "just before [she] wanted to call and ask a question.” Due to continued calls about ear pain, an expected post-op finding, messaging was updated. Continued review of feedback and nursing calls will guide Tonsil Texts changes.
Implications: Caregivers often struggle managing postoperative pain, hydration, and other concerns for up to 2 weeks after surgery. Tonsil Texts reinforces education on postoperative care symptoms and management, normalizing their child’s experience, and providing easy access to the ENT department if additional concerns arise. Nurses may work with their IT departments to create automated processes, such as Tonsil Texts, that support the needs of patients and families. Implementing health literacy practices in post-surgical teaching and innovating methods to improve information retention can improve patient outcomes and reduce costs.
Purpose: To utilize a text messaging program, Tonsil Texts, to decrease ED visits after tonsillectomy, provide support and education to caregivers, and provide access to contact ENT with concerns.
Methodology: This quality improvement project was one implementation strategy in a larger health literacy initiative. Staff conducted a root cause analysis and created a key driver diagram to identify barriers. Two barriers to caregiver retention of information were identified, including delay between visit and surgery and the amount of information provided. To address these barriers, Tonsil Texts were initiated. Systemwide analytics built a report including all patients undergoing tonsillectomy, which communicated with PatientEXP software to send automated text messaging in English or Spanish. All patients were enrolled beginning December 2022, but could opt-out. Families received post-op video instructions on the child's surgery date, providing time to watch while their child was in the operating room. Additional messages were sent on post-op days 2, 4, and 7 with reinforcement of care and encouragement. All messaging included a hyperlink to the patient portal and the clinic phone number. A survey was sent on day 14, indicating the end of standard messaging and post-op period, and requesting feedback on program timeline and messaging.
Results: Our ENT surgeons have completed 729 tonsillectomies in 2023, with 80 patients returning to the ED within 30 days (10.97%). This shows trending improvement from 2022 where 13.7% of patients returned (n=1299), and 2021 where 13.4% returned (n=967). As of June 2023, 96.15% of caregivers found Tonsil Texts helped to manage their child’s pain after surgery (n=78). 98.72% found the Tonsil Texts information was useful and delivered on the appropriate days and times. 97.44% indicated that the messaging helped them know who to contact for concerns. Caregivers reported positive feedback suggesting the texts "helped [her daughter] cope," were received "right on time," and came through "just before [she] wanted to call and ask a question.” Due to continued calls about ear pain, an expected post-op finding, messaging was updated. Continued review of feedback and nursing calls will guide Tonsil Texts changes.
Implications: Caregivers often struggle managing postoperative pain, hydration, and other concerns for up to 2 weeks after surgery. Tonsil Texts reinforces education on postoperative care symptoms and management, normalizing their child’s experience, and providing easy access to the ENT department if additional concerns arise. Nurses may work with their IT departments to create automated processes, such as Tonsil Texts, that support the needs of patients and families. Implementing health literacy practices in post-surgical teaching and innovating methods to improve information retention can improve patient outcomes and reduce costs.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Tags:
pediatrics
nurse chat
Updated: 03/28/24
Patients have historically utilized various methods of communication to schedule an appointment, request medication refills, or seek medical advice to determine the necessary level of care. Patients verbalized increased frustration with hold time for a phone agent or message portal response times. Across the nation, health care has shifted to a higher utilization of virtual services as a means of communication and car advice. Extended message response times by medical personnel continue to be impacted by illness surges, message volume fluctuations, or staffing concerns. Chat has become an increasingly popular alternative. With consideration to the aspects of user experience, we determined that “on-the-go” digital communication is preferred and personalized messenger-based experiences are currently ranked 2nd as preferred means of communication.
Objective of the pediatric live chat: Ensure patient needs are met during viral illness surges. Increase access to healthcare services/ decrease unnecessary ED and UC utilization. Offer personalized advice via access to patient electronic health record to achieve high satisfaction.
Description: With assistance from a secure digital patient communication platform, our healthcare system developed a program that provides the community with additional tools, connecting them to a team of highly qualified pediatric registered nurses. The live chat feature accommodates general medical advice, immediate medical triage, and transfer of message to the primary care practice when needed, eliminating back-and-forth messaging via the patient portal.
Outcomes: Patients requiring triage are fully assessed via the chat. Triage protocols are utilized to determine the disposition and appropriate level of care. Depending on the final disposition, the patient is either provided with at-home care advice, scheduled for an appointment with their PCP, referred to urgent care or ED, or set up with a virtual visit via the on-demand platform.
Data: We have received over 20,000 chat requests since inception. Approximately 50% of the chats are triage in nature. Recent expansion with hours of availability being 7 am – 7 pm/7 days per week.
Parent Feedback: “Chat has been helpful for me to have reassurance, troubleshoot symptoms, and determine the next best steps for caring for my child.” “They helped give me guidance on what to observe, when to make a visit/reach back out, and took the time to message me through my patient portal with some helpful information about fevers in infants.” “The real-time messaging, discussion and support helped me stay calm, feel heard, and get immediate advice and guidance.”
Objective of the pediatric live chat: Ensure patient needs are met during viral illness surges. Increase access to healthcare services/ decrease unnecessary ED and UC utilization. Offer personalized advice via access to patient electronic health record to achieve high satisfaction.
Description: With assistance from a secure digital patient communication platform, our healthcare system developed a program that provides the community with additional tools, connecting them to a team of highly qualified pediatric registered nurses. The live chat feature accommodates general medical advice, immediate medical triage, and transfer of message to the primary care practice when needed, eliminating back-and-forth messaging via the patient portal.
Outcomes: Patients requiring triage are fully assessed via the chat. Triage protocols are utilized to determine the disposition and appropriate level of care. Depending on the final disposition, the patient is either provided with at-home care advice, scheduled for an appointment with their PCP, referred to urgent care or ED, or set up with a virtual visit via the on-demand platform.
Data: We have received over 20,000 chat requests since inception. Approximately 50% of the chats are triage in nature. Recent expansion with hours of availability being 7 am – 7 pm/7 days per week.
Parent Feedback: “Chat has been helpful for me to have reassurance, troubleshoot symptoms, and determine the next best steps for caring for my child.” “They helped give me guidance on what to observe, when to make a visit/reach back out, and took the time to message me through my patient portal with some helpful information about fevers in infants.” “The real-time messaging, discussion and support helped me stay calm, feel heard, and get immediate advice and guidance.”
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/29/24
Introduction: The modern healthcare environment increasingly relies on telephone triage as an effective method to allocate medical resources and provide timely care. Pre-licensure BSN nursing students often find themselves inadequately prepared for this challenging yet crucial aspect of nursing practice. This educational gap necessitates the integration of innovative pedagogical strategies to simulate real-world scenarios, thus enhancing students' competence and confidence in telephone triage.
Methodology: To address this need, we designed a unique simulation exercise using ChatGPT, a sophisticated language model, as a simulated patient in telephone triage scenarios. The simulation encompasses a variety of clinical situations, such as assessing chest pain, managing fever in a child, and responding to symptoms of a potential stroke. Faculty members oversee the simulation, offering real-time feedback and subsequently facilitating a comprehensive debriefing session. Alignment with evidence-based practice: This simulation model aligns with established evidence-based guidelines for nursing education, including the concepts of repetitive practice for skill acquisition and faculty-led debriefing for reflective learning. Preliminary observations and faculty feedback indicate a marked improvement in students' confidence levels and clinical reasoning abilities.
Learning objectives: By the end of the simulation, the learner will demonstrate a comprehensive understanding of the steps involved in telephone triage, adhering to established guidelines and protocols. By the end of the simulation, the learner will employ clinical reasoning to effectively prioritize patient concerns and recommend appropriate interventions. By the end of the simulation, the learner will articulate medical advice or recommendations to the simulated patient (ChatGPT) clearly, empathetically, and accurately.
Expected outcomes: Enhanced student self-efficacy in executing telephone triage, as measured by pre- and post-simulation self-assessment surveys. Demonstrable improvement in students' clinical reasoning skills, evaluated through faculty scoring rubrics. Improved communication skills, assessed through faculty observation and peer reviews, utilizing validated communication assessment tools.
Learning outcome: At the conclusion of this presentation, attendees will gain insights into designing and implementing a realistic, scalable, and cost-effective telephone triage simulation using ChatGPT. This innovative approach has the potential to significantly impact the development of clinical reasoning and communication skills in nursing students. By adopting this multi-faceted simulation approach, nursing education programs can better prepare students for the complex demands of telephone triage, thereby enhancing patient care quality and safety.
Methodology: To address this need, we designed a unique simulation exercise using ChatGPT, a sophisticated language model, as a simulated patient in telephone triage scenarios. The simulation encompasses a variety of clinical situations, such as assessing chest pain, managing fever in a child, and responding to symptoms of a potential stroke. Faculty members oversee the simulation, offering real-time feedback and subsequently facilitating a comprehensive debriefing session. Alignment with evidence-based practice: This simulation model aligns with established evidence-based guidelines for nursing education, including the concepts of repetitive practice for skill acquisition and faculty-led debriefing for reflective learning. Preliminary observations and faculty feedback indicate a marked improvement in students' confidence levels and clinical reasoning abilities.
Learning objectives: By the end of the simulation, the learner will demonstrate a comprehensive understanding of the steps involved in telephone triage, adhering to established guidelines and protocols. By the end of the simulation, the learner will employ clinical reasoning to effectively prioritize patient concerns and recommend appropriate interventions. By the end of the simulation, the learner will articulate medical advice or recommendations to the simulated patient (ChatGPT) clearly, empathetically, and accurately.
Expected outcomes: Enhanced student self-efficacy in executing telephone triage, as measured by pre- and post-simulation self-assessment surveys. Demonstrable improvement in students' clinical reasoning skills, evaluated through faculty scoring rubrics. Improved communication skills, assessed through faculty observation and peer reviews, utilizing validated communication assessment tools.
Learning outcome: At the conclusion of this presentation, attendees will gain insights into designing and implementing a realistic, scalable, and cost-effective telephone triage simulation using ChatGPT. This innovative approach has the potential to significantly impact the development of clinical reasoning and communication skills in nursing students. By adopting this multi-faceted simulation approach, nursing education programs can better prepare students for the complex demands of telephone triage, thereby enhancing patient care quality and safety.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/07/24
Purpose: The purpose of this cross-sectional correlational pilot was to determine the relationship between depression and/or anxiety to health literacy within the primary care population.
Background/significance: Little is known about the impacts mental health has on health literacy. Previous studies researched health literacy and its relationship to depression from the perspective of aggregated and disaggregated racial/ethnic groups or looked at the relationship between parental health literacy and depression to the risk of injury for children. However, there is a lack of understanding related to the relationship between anxiety and depression to health literacy.
Method(s): Manual chart reviews were conducted to identify patients who qualified for the study. The patients who met the inclusion criteria of 18-99 years old, English speaking, patient health questionnaire (PHQ-9) greater than 3, geriatric depression scale (GDS) greater than 5, diagnosis or follow-up visit with office since January 2022 with the ability to return to the clinic were identified. Patients were outreached through the electronic medical record requesting participation in the study. If interested, patients were scheduled to meet with the principle investigator (PI). The PI obtained consent from the participant, and then the participant completed the following questionnaires: PHQ-9 (or GDS), general anxiety disorder (GAD-7), and health literacy skills instrument short form (HLSI-SF).
Result(s): A total of 93 individuals were qualified for the study. 23 individuals indicated they were interested in completing the study and nine were able to complete the study. Three individuals tested for adequate health literacy, and six had inadequate health literacy. One individual tested with adequate health literacy and completed the study within the estimated amount of time of 20 minutes. The average amount of time to complete the study was 29.5 minutes, with a range of 17-80 minutes. As depression increased in severity, health literacy decreased. As anxiety increased in severity, health literacy decreased.
Conclusions/implications: There is a correlation that as depression and anxiety increase, health literacy decreases. Two-thirds of the individuals that had adequate health literacy did not complete the study in the estimated amount of time. The average amount of time for a primary care appointment is 20 minutes. However, this study indicates that patients with mental health concerns require extended time to understand and navigate the healthcare system. Increasing awareness of a patient's health literacy needs may impact compliance rates for patients. Having a better understanding of the risk factors (comorbidities and demographics) attributing to high depression/anxiety scores and low health literacy may help staff better identify potential patients at higher risk for depression/anxiety and health literacy.
Background/significance: Little is known about the impacts mental health has on health literacy. Previous studies researched health literacy and its relationship to depression from the perspective of aggregated and disaggregated racial/ethnic groups or looked at the relationship between parental health literacy and depression to the risk of injury for children. However, there is a lack of understanding related to the relationship between anxiety and depression to health literacy.
Method(s): Manual chart reviews were conducted to identify patients who qualified for the study. The patients who met the inclusion criteria of 18-99 years old, English speaking, patient health questionnaire (PHQ-9) greater than 3, geriatric depression scale (GDS) greater than 5, diagnosis or follow-up visit with office since January 2022 with the ability to return to the clinic were identified. Patients were outreached through the electronic medical record requesting participation in the study. If interested, patients were scheduled to meet with the principle investigator (PI). The PI obtained consent from the participant, and then the participant completed the following questionnaires: PHQ-9 (or GDS), general anxiety disorder (GAD-7), and health literacy skills instrument short form (HLSI-SF).
Result(s): A total of 93 individuals were qualified for the study. 23 individuals indicated they were interested in completing the study and nine were able to complete the study. Three individuals tested for adequate health literacy, and six had inadequate health literacy. One individual tested with adequate health literacy and completed the study within the estimated amount of time of 20 minutes. The average amount of time to complete the study was 29.5 minutes, with a range of 17-80 minutes. As depression increased in severity, health literacy decreased. As anxiety increased in severity, health literacy decreased.
Conclusions/implications: There is a correlation that as depression and anxiety increase, health literacy decreases. Two-thirds of the individuals that had adequate health literacy did not complete the study in the estimated amount of time. The average amount of time for a primary care appointment is 20 minutes. However, this study indicates that patients with mental health concerns require extended time to understand and navigate the healthcare system. Increasing awareness of a patient's health literacy needs may impact compliance rates for patients. Having a better understanding of the risk factors (comorbidities and demographics) attributing to high depression/anxiety scores and low health literacy may help staff better identify potential patients at higher risk for depression/anxiety and health literacy.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
