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P014 - Assessing Ambulatory Care Settings for Safe Patient Handling Resources and Training
Lindsay Gatton, MSN, RN, NPD-BC    |     Kiana Scott, MSN, RN, NPDS, CNML, CCRN-K
Tags: education outpatient safe patient handling mobility learning needs

Updated: 03/07/24
Objectives: Discuss how to complete a survey assessment to evaluate learning needs. Discuss an interdisciplinary approach to creating an education bundle.

In July 2021, a patient required transfer assistance from wheelchair to exam table. Lift equipment and lift team resources were not in place to support the patient and clinic needs. Ambulatory care staff involved in shared governance escalated this issue to organizational leadership. It was discovered that the lack of available lift equipment and resources was not unique to this clinic alone.

While a standardized safe patient handling (SPH) training program and access to resources were well established in the inpatient setting, lift team support and training plans did not extend to ambulatory care clinics. SPH hands-on training was inconsistently utilized in the ambulatory care setting and knowledge of processes, policies, and scope of practice varied by department. Current SPH training (initial and ongoing) did not include ambulatory care-specific roles, guidelines, equipment, or space consideration in the ambulatory care setting. A workgroup was assembled to identify equipment, training needs, and a plan for sustainable ambulatory care-focused education.

The project leads gathered data from each clinic by conducting a survey of current SPH practices, education, resources, available lift equipment, a physical assessment of clinic space, and patient population needs. The survey had a 69% response rate and included feedback from 80 cost centers and 32 clinic locations and revealed 60% of staff never received education or orientation to SPH resources. The survey also provided a list of existing lift equipment in each location and frequency of SPH needs.

The survey identified lack of staff training and allowed for assessment of equipment needs in individual clinics. The workgroup was expanded to include a subject matter expert (SPH program manager), clinical nurses, and medical assistants. Together, this interdisciplinary team developed an ambulatory care-focused SPH education bundle that included a didactic learning module, hands-on skills training, and the expansion of a lift champion training model to all clinic departments in lieu of lift team support. Simultaneously, the SPH program manager utilized survey data to guide equipment recommendations. Due to space constraints and patient needs, not all clinics required the use of additional equipment.

As a result of the workgroup’s collaboration, 20 clinic locations were assessed, and five clinics obtained new lift equipment based on their patient population needs. Over 1000 staff members completed the new didactic module, demonstrating 98% training compliance, and 600 clinical nurses and medical assistants completed hands-on SPH training. Prior to this intervention, ambulatory care service lines had 22 SPH champions. Following the intervention, the number of SPH champions increased by 522%, 137 champions representing 80 cost centers. To ensure regulatory compliance and sustainability, the didactic module and hands-on training will be completed annually and within 30 days of hire for new staff members.

Implication for practice: The use of a needs assessment survey can be a powerful way to not only assess learning needs, but resource needs to support safe practice in the ambulatory care setting.

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.

P015 - Multifactor Intervention to Reduce TNP Results of HIV Lab Orders Within a Community Health Center
Cindy-Lou Killikelly, MSN, RN, AMB-BC    |     Rebecca Kwon, RN
Tags: primary care ambulatory care hiv specimen errors

Updated: 03/07/24
Background: An estimated 190,000 patients living with, or at risk of contracting HIV, receive primary care at community health centers (CHC). HIV labs are an essential part of routine care and are utilized to determine the viral load, which is necessary to develop a care plan. A result of “test not performed” (TNP) occurs when there is an error processing the lab work. TNP results create an additional burden for both the patient and their providers and potentially delay proper care planning.

Method: In response to the prevalence of TNP results, the nursing team at a New York City CHC implemented a multifactor intervention in April 2023 to reduce TNP results. The intervention included email and instant message reminders, a time-out system where two medical office assistants confirm patient information to label the lab orders, verbal and written warnings for employees with multiple associated TNPs, a countdown board of days since the last TNP result, and a lab requirement cheat sheet. To evaluate outcomes, we examined electronic health record data on orders placed before intervention (January 1st, 2023, through April 16, 2023) and after intervention (April 17, 2023, through October 31st, 2023) to calculate the average monthly rate of TNPs and number of days between TNPs. Senior nursing leadership solicited informal feedback and documented successes and barriers.

Results: Over the period of observation, the site performed over 1,200 HIV labs, with 2.5% of labs resulting in TNP. Before the implementation, there were 22 TNP results, with an average of 4.9% results being TNP. After implementation, there were 7 TNP results, with an average of 1.1% results being TNP. The average number of days between TNPs increased after intervention from an average of 4.2 days between TNPs pre-intervention and 20.4 days post-intervention.

Discussion: The intervention experienced some limitations. Staffing challenges did not allow for the time-out system during busy clinical hours because it would delay patient care. The disciplinary system of warnings also had a perceived negative impact on staff morale. Additionally, TNPs can result from errors within laboratories independent of clinical staff; manual audits would determine the exact cause of TNP error. Despite these challenges, the multifactor intervention was shown to be successful in lowering the rate of TNPs at the center. Future research is needed to examine the causes of continuing TNPs to improve intervention, the sustainability of the intervention, and its application to other types of lab orders.

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.

P016 - Improvement of Immunization Rates in the Adolescent and Young Adult Medicine Practice
Hannah Rauchle, RN    |     Kathleen Waddicor, BSN, RN, CPN
Tags: immunizations quality improvement

Updated: 03/07/24
Background/significance: Per the advisory committee on immunization practices, “achieving and maintaining high vaccination coverage levels for adolescents will ensure they have protection from serious and sometimes life-threatening vaccine-preventable diseases.” Complete immunization records are important to help prevent infectious diseases and provide access to opportunities such as school, work, and sports. Complete immunization records may also minimize healthcare costs and prevent using extra doses of immunizations or checking lab titers to unnecessarily prove immunization status. As of April 2022, the nursing team collaborated with the current adolescent quality improvement immunizations team, who started this project in January 2020, to develop processes to increase immunization rates in our new primary care and current adolescent population.

Purpose and goals: Increase the percentage of immunizations records received for new primary care adolescent patients prior to or at their first appointment. Increase the percentage of current adolescent patients ages 12 to 16 with 15 + immunizations from 80% to 90% by September 2023. Increase the percentage of adolescent patients who are up to date on meningitis ACWY from 72% to 80% by September 2023.

Methods: Import immunization records from the Massachusetts Immunization Information System (MIIS) into the adolescent patient’s profile. Outreach to patients and/or parent without immunization records to obtain them prior to or at the adolescent patient’s first primary care appointment. Review new primary care adolescent patient’s immunization records and send a Power Chart message to the provider they are seeing outlining which immunizations are needed at their visit. Place alerts in current adolescent patient’s appointment note in EPIC if they are overdue for meningitis ACWY.

Findings: From April 2022 to September 2023, 93% of new primary care adolescent patient’s records have been entered before or at their first appointment in our office. From April 2022 to September 2023, 92.1% of adolescent patients ages 12 to 16 have 15+ immunizations. From April 2022 to September 2023, 87.5% of adolescent patients are now up to date on meningitis ACWY.

Implications/next steps: Place alerts in current adolescent patient’s appointment note in EPIC if they are overdue for Tdap and HPV. Increase percentage of adolescent patients who are up to date on meningitis ACWY from 80% to 90% by December 2023. Increase percentage of adolescent patients who are up to date on Tdap from 87% to 90% by December 2023. Increase percentage of adolescent patients who are up to date on HPV from 73% to 80% by December 2023.

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.

P017 - How Patient Visit Planning Has Improved HIV Screening Rates Among FQHC Patients in Detroit
Keri Urquhart, MPH, BSN, RN
Tags: health outcomes patient visit planning Azara HIV screening

Updated: 03/28/24
Problem: In Michigan, HIV prevalence continues to increase because the number of new diagnoses is larger than the number of deaths. Detroit has the highest HIV prevalence rates in the state. In 2022, Detroit had more NEW HIV cases than the other top 20 cities with largest HIV counts combined. The percentage of new HIV diagnoses that were diagnosed late, in 2020 was16.2%. A late HIV diagnosis is defined as having an AIDS diagnosis within three months of initial HIV diagnosis, leading to poorer outcomes. The CDC recommends that everyone between the ages of 13 and 64 should get tested for HIV at least once as part of routine health care. Early HIV diagnosis improves patient outcomes, reduces the burden of undiagnosed HIV, and limits transmission.

Rational: Patient visit planning helps the patient and physician conduct a face-to-face visit more effectively by gathering and organizing information and adding orders ahead of time so they can devote more attention during the visit to interpreting, discussing, and responding to that information, and addressing patient needs. HIV screening is done within the clinics; staff efforts immediately impact/improve health outcomes and quality data.

Approach: Patient visit planning protocol developed based on feedback from providers and medical assistants (MAs) regarding needs, workflow, and implementation in clinics: use of AZARA DRVS platform for patient visit planning; initially focused on 3 major cancer screening metrics: colonoscopy, mammogram, and pap smears; protocol included built-in order sets in electronic medical records (EMR) for MAs to use when chart prepping for visits; expanded to include other elements of adult wellness visits including HIV screening.

Results: HIV screening average for our clinics increased from an overall 42% in 2021 to an overall 58% this year; and one of our individual health centers reached 77%. The health center average in the state of Michigan is 33% for 2023.

Addressing barriers: Shortly after PVP was introduced to clinics, a survey went out to providers and MAs to determine how it was going, including any barriers to PVP in the clinics. Several steps were taken to address those barriers identified and help improve the PVP process in the clinics, including training, regular feedback and follow-up, reinforcement, enhanced PVP instructions, including alerts with specific directions for MAs to follow when prepping charts, the use of order sets in EMR to reduce time and create common workflows across sites, and integration of AZARA directly into EMR.

Conclusion: Nearly 40% of new HIV infections are transmitted by people who don’t know they have the virus. For people with undiagnosed HIV, testing is the first step to accessing treatment for maintaining a healthy lifestyle and preventing HIV transmission. Integrating patient visit planning HIV testing into primary care daily workflow can improve HIV testing at a population level while using a patient-centered approach.

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.

P018 - The Impact of Telephone Triage on Emergency Use
Loren Dempsey, DNP, RN, PPCNP-BC, AE-C    |     Cristina Mendes, MSN, RN, CPN
Tags: self-management asthma pediatrics telephone consultationtriage asthma action plan emergency room visit caregivers clinical practice guidelines

Updated: 03/07/24
Purpose: This quality improvement (QI) project aimed to assess whether a standardized process for telephone triage, reinforcing caregiver use of the AAP, and documentation impacted ED visits and nursing practice.

Description: National asthma education guidelines and current evidence promote asthma self-management education at all contacts and using an asthma action plan (AAP) to improve life quality and reduce healthcare costs and emergent care needs. Emergency department (ED) visits are preventable, with a local report citing that most pediatric patients who sought ED evaluation in the prior two years did not require hospitalization. We identified that nurses working in a single primary care pediatric setting with high asthma prevalence (14%) did not have an evidence-based process to provide education or document patient/caregiver concerns during telephone triage.

Evaluations: The knowledge-to-action methodology guided the process' development, which included aspects of staff education, assessments, implementation of the patient's AAP during telephone triage, and smart-phrase documentation. To inform differences, ED visits, call volume, and intervention fidelity were observed over eight weeks pre-and post-intervention.

Outcome: Positive changes were observed pre- to post-process intervention. Improvements were noted in nursing recommendations adhering to practice standards: triage assessment documentation (p = 0.014), AAP education (p < 0.001), and follow-up advice (p < 0.001). No statistical difference in ED visits was identified between time periods (p = .40). A significant finding was that ED visits following a nurse triage encounter were much lower than visits without a preceding nurse encounter, 22.2% vs. 77.8%, respectively. Improvement was observed in Press Ganey score answering phones (+37.5%) in the first quarter post-intervention.

Conclusions/implications for practice: Assessment helped to inform a reliable telephone triage process to improve call documentation and nurse use of asthma education guidelines at all contacts. Efforts to encourage contact with the clinic, deployed from check-in to checkout, may explain improved scores for call satisfaction, but it did not lead to higher call volume. A significant takeaway from this project was an assessment of ED patterns. We learned that most caregivers did not call for advice; more education is needed to support caregivers calling the clinic for advice. The project's importance was that it highlighted the patients that can be supported by the healthcare team with evidence-based education when asthma symptoms develop. Next steps include interventions aimed at caregiver contact, expanding triage support, and continued tracking of ED visits and call volume until a downward shift is sustained.

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.

P019 - Ambulatory Care Nurse-Led Initiative: Controlling Blood Pressure for Patients with Diabetes
Rosa Tenorio, BSN, RN-BC
Tags: education collaboration diabetes quality improvement hypertension

Updated: 03/28/24
Background: According to Centers for Disease Control and Prevention (CDC, 2022), high blood pressure is a common condition that can have serious health consequences, contributing to nearly 500,000 deaths per year in the United States. Nearly 1 out 2 adults have high blood pressure and 6 out of 10 who have diabetes also have high blood pressure. Fortunately, high blood pressure is preventable and treatable. Anti-hypertension education and counseling is an important intervention to decrease the mortality and disease burden.

Objectives: In January 2022, the ambulatory care health center’s high blood pressure control for patients with diabetes score was 72%. The data included a numerator of 863 and a denominator of 1,198. Measure data includes a numerator of diabetic patients with controlled elevated blood pressure ages 18-75 years old and a denominator of the total number of diabetic patients within the measurement year. National Committee for Quality Assurance (NCQA) goal for the high blood pressure control (

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.

P020 - Taming the EMR Dragon: A Tale of Optimization Triumph Over Nursing Burnout
Kristen Brady, MSN, MBA, RN    |     Samantha English, MSN, RN    |     Amber Owens, BSN, RN
Tags: scope of practice burnout HER optimization

Updated: 03/07/24
Increased workloads in ambulatory care paired with critically low staffing levels have contributed to increased burnout of nurses and care providers. According to a meta-analysis by Moy et al. (2021), ambulatory care nurses and providers spend twice as much time on electronic documentation and clerical tasks in the EMR, e.g., EMR in-basket management, telephone encounters, and paperwork, which play a large role in increased workloads leading to an increased in errors, poor documentation quality, threats to patient safety, and ultimately burnout. Social trends of instant messaging and virtual communication have changed patient preferences and expectations regarding communication and care delivery in health care. Additionally, challenges related to appropriate clinical care and a variety of scopes/competencies within the ambulatory care setting add to the complexity of delivering high-quality patient care and meeting patient satisfaction.

Our interdisciplinary team recognized the increased workload as a source of burnout, leading to the need for optimizing workflows, maximizing EMR features, and promoting clinical staff working at the top of their scope. A workgroup was formed, aimed at providing in-person meaningful education to staff focused on appropriate use of smart phrases, actionable items, and EMR efficiency tools. Education sessions consisted of 4-hour in-person sessions held in varying locations throughout the clinic region from September to December 2023. Education sessions were conducted in a manner to facilitate dialogue, feedback, and requests from attendees. The education became a “living document” that was continually updated and honed to the needs of the staff and the scope of their practice. Post-education “at the elbow” support and clinic rounding are scheduled to be implemented during the first quarter of 2024 with a goal of assisting staff with implementing EMR customization tools.

To measure the impact of the education, staff were asked to take pre- and post-surveys regarding their base knowledge and the effectiveness of the education. Pre-survey's confirmed the workgroup's initial suspicion that a deficit in knowledge and practice of actionable items was low-hanging fruit, in addition to the fact that staff feel overwhelmed with their workload and cannot get their tasks completed within expected timeframes. Post-survey data showed that 65% of attendees planned to make changes to their practice. Attendee survey feedback identified a variety of stated optimization methods. Survey data collection is not complete at the time of abstract submission, as education sessions are planned through the end of the year.

Both anecdotal and survey response to education content and presentation format confirmed the need for and value of incorporating optimization, efficiencies, and professional electronic communication into staff training. The need to professionally communicate expectations regarding what platforms are most appropriate for various care needs became an important tool to help reduce burnout and improve patient satisfaction and quality of care.

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.

P021 - Improving Access to Care through Ambulatory Care Nurse Visits
Kathleen Booker, RN    |     Gloria McGilberry, MS, RN, AMB-BC
Tags: access primary care chronic disease nurse visits team-based approach

Updated: 03/07/24

One common problem faced by primary care practices today is the limited access for patient appointments. “With larger numbers of older adults comes an increased need for primary care, including care for individuals with chronic physical and mental health diagnoses and comorbidities. A total of 60% of adults in the United States have at least one chronic illness and 42% have multiple chronic illnesses.” Nurses working at the top of their license can provide education to help patients prevent or improve management of their chronic disease. These nurses, who have the clinical skills, knowledge, and experience can provide care for patients with chronic diseases by performing nurse visits. “Physicians and advanced practice providers alone cannot meet the growing demand for primary care. Registered nurses working to the full extent of their licenses will be needed at the front lines of care delivery.” Through collaboration with the providers, nurses partner with the patient by driving patient self-management of their chronic disease with a plan to influence lifestyle changes.

A chronic condition that is preventable and treatable is “high-blood pressure (also known as hypertension) is a common condition that can have serious health consequences, contributing to nearly 500,000 deaths per year in the United States. Nearly 1 out of 2 adults—around 108 million—have high blood pressure, and only 1 in 4 have their condition under control.” Using a team-based approach, the nurses and providers in our primary practices strategize and develop care management of the hypertensive patient. By using this approach, nurses work at the top of their license by providing nurse visits, which are driven by the care of the primary care provider.

The in-person visits require specific criteria that must be met prior to the nurse visit. If the criteria are met, the visits are billable, by using the CPT code 99211. At our organization, we partnered with our financial and data team to differentiate nurse and provider visits. This request was achieved by adding RN to the end of the 99211 CPT code (i.e., 99211RN). A report is generated weekly providing the number of billable visits completed by the nurse. Primary care nurse visits were initiated in March 2022, and by the end of the fiscal year, 209 visits had been completed. These visits increased to 811 in fiscal year 2023.

Barriers were identified after implementing nurse visits, such as high triage call volume, staffing vacancies, and other demands of the practice. Sadly, not all providers have supported nurse visits; however, with increased need for access, our providers have begun to recognize the benefits of the team-based approach on chronic disease management. Currently, all billable nurse visits occur in our organization’s primary care practices; however, we are working toward expanding into our specialty practices. It’s a work in progress.

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.

P022 - Navigating Discharge Planning Phone Calls in Orthopedics
Elizabeth Krebsbach, LPN    |     Kelsie Nelson, MBA/HCM, RN, Ambulatory Nurse Manager, Department of Orthopedics, Mayo Clinic
Tags: telehealth lpn optimization perioperative redesign

Updated: 03/07/24
Purpose: While a nursing discharge planning processes existed within the ambulatory care orthopedic practice, the post-pandemic changes of the total arthroplasty patient prompted further examination and redesign of the existing processes for scope of licensure, resources utilization and assessment of telehealth standards within scope of practice of the licensed practical nurse (LPN).

Description: The department of orthopedics has a strong history of prioritizing successful dismissal post-surgery processes by addressing dismissal plans early in the perioperative process. During the COVID pandemic, the total joint arthroplasty practice needed to shift to outpatient surgery more quickly than initially planned. This change in practice increased the importance of preoperative discharge planning. To align with organizational practice redesign and role optimization priorities, the previous registered nurse (RN)-led process was converted to a purely LPN-led process and optimized for practice and role efficiency adhering to telehealth best practices.
Reviewed process to determine potential to standardize. Established a standard workflow for communication with multidisciplinary team members. Developed functional work queue to optimize call prioritization and reduce rework. Developed training incorporating telehealth best practices. Standardized the process flows and consolidated documentation for multiple joint replacement procedures.

Evaluation/outcomes data was collected on the discharge planning phone calls to assist in determining call volume of the orthopedic surgical population reached pre- and post-implementation of the new process. Nursing satisfaction was evaluated pre- and post-implementation by anonymous electronic survey method. A work group consisting of orthopedic nurse leaders and departmental LPNs was created to identify inefficiencies in the current discharge planning phone call procedure and seek multidisciplinary input from stakeholders involved in the process. The LPN group created a standardized process, resource toolkit, telehealth best practice education, and electronic health record report to assist with providing an efficient and quality experience for both the patient and the nursing staff.

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.

P023 - Back to the Basics: A Quality Improvement Program to Enhance Clinical Staff Use of Evidence-Based Standard Blood Pressure Measurement Techniques
Brittney Dees, DNP, RN, CPN, Staff Development Specialist, UK Healthcare     |     Sara Wellman, MSN, APRN, FNP-C, Clinical Nurse Specialist, University of Kentucky Healthcare
Tags: education blood pressure hypertension quality measure clinical competency

Updated: 03/07/24
Learning objective: Evaluate the use of a skills-based education program to improve clinical staff (RNs, LPNs, and medical assistants) competence in providing an evidence-based technique for measuring BP and improving BP control in our primary care clinics.

Background: Uncontrolled hypertension is one of Kentucky’s leading health problems and contributes to poor patient outcomes. Accurate measurement of blood pressure (BP) is critically important in primary care, but ambulatory care BP measures are inherently problematic. Many experienced clinicians do not measure BP accurately because they either take shortcuts or lack knowledge regarding the appropriate technique. Inaccurate BP assessment can lead to inadequate diagnoses of hypertension (HTN). The standard evidence-based technique for measuring BP includes having the patient seated for 3-5 minutes in a quiet room with legs uncrossed, not talking, and back supported. BP should be re-checked after 5 minutes if elevated. In-office BP measurement using a correct size, upper-arm cuff constitutes the evidence-based reference method for current BP classification and treatment targets.

Methods: This quality improvement project will utilize the plan-do-study-act (PDSA) cycle to evaluate the use of a skills-based educational program to improve clinical staff competence in using an evidence-based technique for measuring BP and for improving BP control in primary care clinics. Controlled HTN was defined as the percentage of patients 18-85 years of age who have a diagnosis of HTN whose most recent BP was adequately controlled (

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.

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