Updated: 03/07/24
The clinical nurse education department is responsible for coordinating and facilitating annual mandatory skills competency demonstrations for clinical staff to validate knowledge and skills as required by the regulating agencies. Historically these competencies are completed via simulation with clinical nurse educator or super user after successful review of LMS pre-requisite education. As we have progressed through challenges associated with staffing shortages and COVID-related limitations, staff have had difficulty meeting the requirements of competency validation despite offering a variety of options such as frequent mandatory skills fairs, clinical educator time on units for competencies, increasing the number of super users on units, etc.
As the challenges of COVID have impacted the healthcare industry, research on virtual competency evaluation has begun in the academic realm. Palmer, Chisholm, Rolf & Morris validated the use of self-video recording as a method to validate clinical skill competency in nursing students (2021). The conclusion of this study found that “student success using remote assessment strategies during the spring 2020 semester was similar to the success rate using traditional skill assessment methods in fall 2019.” Similarly, virtual OSCE assessment for student NPs has been validated as an effective method of evaluation, and also “all stakeholders expressed satisfaction with the experience.”
The clinical educators piloted virtual mandatory skills as an additional option for staff to meet their required competency validation in both inpatient and outpatient settings in 2023. This option did not replace existing traditional methods but is an available alternative for those that choose to participate.
Participation in VMS has the same prerequisite requirements as traditional methods, staff first complete prerequisite education in the LMS, as required. Staff then view clinical educator video demonstration of competency in order to ensure that expectations of skill are clear to the staff member. They are provided with all props and supplies necessary for successful completion. Checklists of expectations for each competency are available for reference. Staff use their own digital device to record themselves performing the competency. Staff upload their video to flip for review by clinical educator and the clinical educator provides feedback to staff via email and provide tracker credit for competency that is validated. If staff requires remediation, in-person competency validation may be arranged.
This process has proven to be successful in our outpatient settings from both a front-line staff and manager perspective. Staff expressed satisfaction with convenience of virtual option in comparison to in-person options. Managers expressed satisfaction with time to complete competency in comparison to in-person options. Post-pilot, we will be offering VMS to our entire institution as an additional option to traditional competency offerings.
As the challenges of COVID have impacted the healthcare industry, research on virtual competency evaluation has begun in the academic realm. Palmer, Chisholm, Rolf & Morris validated the use of self-video recording as a method to validate clinical skill competency in nursing students (2021). The conclusion of this study found that “student success using remote assessment strategies during the spring 2020 semester was similar to the success rate using traditional skill assessment methods in fall 2019.” Similarly, virtual OSCE assessment for student NPs has been validated as an effective method of evaluation, and also “all stakeholders expressed satisfaction with the experience.”
The clinical educators piloted virtual mandatory skills as an additional option for staff to meet their required competency validation in both inpatient and outpatient settings in 2023. This option did not replace existing traditional methods but is an available alternative for those that choose to participate.
Participation in VMS has the same prerequisite requirements as traditional methods, staff first complete prerequisite education in the LMS, as required. Staff then view clinical educator video demonstration of competency in order to ensure that expectations of skill are clear to the staff member. They are provided with all props and supplies necessary for successful completion. Checklists of expectations for each competency are available for reference. Staff use their own digital device to record themselves performing the competency. Staff upload their video to flip for review by clinical educator and the clinical educator provides feedback to staff via email and provide tracker credit for competency that is validated. If staff requires remediation, in-person competency validation may be arranged.
This process has proven to be successful in our outpatient settings from both a front-line staff and manager perspective. Staff expressed satisfaction with convenience of virtual option in comparison to in-person options. Managers expressed satisfaction with time to complete competency in comparison to in-person options. Post-pilot, we will be offering VMS to our entire institution as an additional option to traditional competency offerings.
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
Nuclear medicine is becoming an independent specialty, in need of tailored outpatient nursing care. Most hospitals employ nurses to support the clinical needs of nuclear medicine departments. The radiology nurse must keep abreast of new interventions and technological advancements while providing patient-focused care. The National Institutes of Health molecular imaging clinic (MIC) conducts early phase clinical research studies using radioisotopes, radiopharmaceuticals, optical and magnetic resonance agents for diagnostic imaging and targeted for cancer treatment. The impact of adding a clinical nurse to the MIC can increase patient volume, patient acuity, protocol acuity, and patient safety.
In early 2021, a clinical nurse was added to the MIC, extending treatment options, increasing patient assessments, improving patient safety, and increasing the number of patients seen in the clinic. After the addition of a clinical nurse, the clinic has increased the protocol volume from 6 to 11 protocols with 4 additional protocols pending approval. The patient volume increased by 25% for MRI and 64% for PET scans/radiopharmaceutical treatments between 2020-2022. The MIC is now able to consistently complete protocol-related clinical nursing documentation, protocol-mandated nursing assessments, and collection of diagnostic/research samples. Staffing now supports the care for higher acuity patients and protocols requiring specialty procedures like sedation, administration of medications, intravenous line care, and airway assessment/management. Patient safety has improved with quarterly nurse-led emergency management training for staff (radiologists, research nurses, nuclear technologists, nurses, and patient care technicians). Presence of a clinical nurse allows the technologist to focus on patient care duties related to handling/administration of radiation for scans and therapies while the nurse focuses on patient care, patient education, patient advocacy, and safety.
Prior to gaining a clinical nurse, technologists would have to prepare the radioactive treatment dose in the MIC and travel across several buildings to a lead-lined room on an inpatient unit to administer the dose. Now techs can treat patients in the lead-lined rooms in the MIC. This change decreased the possibility of radioactive spills, limited the area of potential contamination to just the MIC, increased throughput to three treatments per day, and lowered cost. Finally, the addition of a clinical nurse in the MIC provides the opportunity to provide broader services in this evolving clinical setting.
In early 2021, a clinical nurse was added to the MIC, extending treatment options, increasing patient assessments, improving patient safety, and increasing the number of patients seen in the clinic. After the addition of a clinical nurse, the clinic has increased the protocol volume from 6 to 11 protocols with 4 additional protocols pending approval. The patient volume increased by 25% for MRI and 64% for PET scans/radiopharmaceutical treatments between 2020-2022. The MIC is now able to consistently complete protocol-related clinical nursing documentation, protocol-mandated nursing assessments, and collection of diagnostic/research samples. Staffing now supports the care for higher acuity patients and protocols requiring specialty procedures like sedation, administration of medications, intravenous line care, and airway assessment/management. Patient safety has improved with quarterly nurse-led emergency management training for staff (radiologists, research nurses, nuclear technologists, nurses, and patient care technicians). Presence of a clinical nurse allows the technologist to focus on patient care duties related to handling/administration of radiation for scans and therapies while the nurse focuses on patient care, patient education, patient advocacy, and safety.
Prior to gaining a clinical nurse, technologists would have to prepare the radioactive treatment dose in the MIC and travel across several buildings to a lead-lined room on an inpatient unit to administer the dose. Now techs can treat patients in the lead-lined rooms in the MIC. This change decreased the possibility of radioactive spills, limited the area of potential contamination to just the MIC, increased throughput to three treatments per day, and lowered cost. Finally, the addition of a clinical nurse in the MIC provides the opportunity to provide broader services in this evolving clinical 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.
Updated: 03/07/24
Pre-pandemic, suicide was the second leading cause of death among teens and young adults, aged 15 to 24 years; in 2019, more than one-third of high-school students aged 14-17 years reported persistent feelings of sadness and hopelessness, with nearly 20% of those individuals seriously considering suicide; and post-pandemic, the suicide rate among adolescents, aged 12 to 18 years, is rising. Of further note, 40% of adolescents who died by suicide had seen a medical provider in the month before their death. The problem identified by this project was pediatric primary care providers (PCPs) are spending more than half their day supporting adolescent and teen patients with mental health needs during a period of rapid physical, emotional, and social development despite having limited mental health training. This issue is further complicated by a lack of access to behavioral health specialists. The project was designed to guide pediatric PCPs and their care teams with early identification of depression among adolescents aged 12 to 18 years, early intervention for positive depression screening, and reduction of suicide risk through 6-8 weeks of active monitoring of the adolescent in the primary care setting. To accomplish this task, a screening, brief intervention, and referral to treatment (SBIRT) toolkit was developed utilizing evidence presented in the 2018 Guidelines for Adolescent Depression in Primary Care (GLAD-PC); and it took into consideration the challenges faced by PCPs when selecting a screening tool and the burden of treatment, time, and accountability related to identification of a positive depression screen. The toolkit contains the 9-item patient health questionnaire (PHQ-9) modified for teens to be utilized as the self-assessment tool; the brief intervention tool, which guides the clinician through non-judgmental interpretation of screening results, further assessment of at-risk behaviors, and safety planning; and a referral to treatment infographic to be provided to the patient/patient’s family with a list of community supports and crisis resources. The SBIRT toolkit was evaluated by five family nurse practitioner (FNP) reviewers. Quantitative feedback showed at least 60% of reviewers were “very likely,” with remaining 40% “moderately likely,” to use the screening and brief intervention tools in clinical practice. Qualitative feedback supported the use of the referral to treatment tool for its depth of resources. Consequently, the SBIRT toolkit may be a viable option to support pediatric PCPs with early identification of adolescent depression while providing compassionate support to the adolescent patient and their family when a positive screen is identified. The goal is to reduce suicide risk through brief intervention and active monitoring of the adolescent patient by the primary care team. The SBIRT toolkit offers a cost-effective and sustainable option for pediatric PCPs to address a healthcare gap in access to behavioral health providers and improve health outcomes for adolescents aged 12 to 18 years who are at risk for depression and suicide.
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: 03/28/24
In 2019, a multidisciplinary learning needs assessment completed by over 100 ambulatory care staff identified they were dissatisfied with interdivisional education across clinics. A workgroup of nursing leaders was formed with the goal to provide evidence-based learning, promote collaboration across specialties, and improve care in the outpatient setting.
The findings of the learning needs assessment resulted in the development of an ambulatory care education series. The following educational goals were identified: advance clinical knowledge, increase confidence managing medically complex patients, and apply knowledge to practice. Next, topics were determined through environmental scanning and outpatient system priorities, and content experts were identified to present monthly. Presentations were recorded and made available online for future reference and supplemental onboarding education.
Since the conception of the series, each session has had an average number of 25 multidisciplinary participants, including nurses, medical assistants, dietitians, orthopedic and radiologic technicians, and clinic leadership. Participants are highly engaged in the sessions and report a better understanding of interdivisional education. Pre- and post-evaluation surveys show an increase in learner knowledge and confidence. It is anticipated the education series will continue to foster collaboration among ambulatory care departments and promote excellent patient care in a complex and changing environment.
In October 2023, a follow-up learning needs assessment was sent to ambulatory care staff to gather feedback about the clinical impact of the education series. 65 responses were collected and common themes on impact to practice were whole childcare, resiliency, electronic medical communication, case management resources, and annual vaccine education. This education series increases staff ability to utilize resources and to provide effective care of patients in the ambulatory care setting.
The findings of the learning needs assessment resulted in the development of an ambulatory care education series. The following educational goals were identified: advance clinical knowledge, increase confidence managing medically complex patients, and apply knowledge to practice. Next, topics were determined through environmental scanning and outpatient system priorities, and content experts were identified to present monthly. Presentations were recorded and made available online for future reference and supplemental onboarding education.
Since the conception of the series, each session has had an average number of 25 multidisciplinary participants, including nurses, medical assistants, dietitians, orthopedic and radiologic technicians, and clinic leadership. Participants are highly engaged in the sessions and report a better understanding of interdivisional education. Pre- and post-evaluation surveys show an increase in learner knowledge and confidence. It is anticipated the education series will continue to foster collaboration among ambulatory care departments and promote excellent patient care in a complex and changing environment.
In October 2023, a follow-up learning needs assessment was sent to ambulatory care staff to gather feedback about the clinical impact of the education series. 65 responses were collected and common themes on impact to practice were whole childcare, resiliency, electronic medical communication, case management resources, and annual vaccine education. This education series increases staff ability to utilize resources and to provide effective care of patients 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.
Tags:
patient safety
medication administration
ambulatory care medication administration
BCMA
safe medication administration
Updated: 03/28/24
Barcode medication administration (BCMA), a standard workflow in the acute care environment, is rarely used in the ambulatory care setting where medications and vaccines are frequently administered. The goal of BCMA is to align with principles and behaviors of causing no harm by providing a safe, consistent workflow to mitigate medication errors. As noted by Seibert (2014), the most common method of identifying medication administration errors is through voluntary reporting. An online portal for adverse event reporting was utilized throughout the project. To prepare for the pilot, multidisciplinary site visits were conducted to assess the quantity of scanners needed, current inventory of hardware, subsequent configuration, and team member training. The BCMA project launched at 5 pilot practices (3 family medicine, 1 internal medicine, and 1 pediatric) to provide an additional layer of patient safety. The pilot reinforced verifying the five rights of medication administration: right patient (identified verbally with two identifiers), right medication, right dose, right time, and right route. Post-go-live surveys were sent at 30-day and 60-day intervals to assess team members’ adaptiveness of the BCMA workflow, and site visits were conducted to provide support and education. Monthly adverse event reports were analyzed to trend medication administration related errors. Additionally, a BCMA Microsoft Power BI dashboard was created and utilized to review scanning rates and details, including scanning compliance and near misses. The scanning compliance goal was 95%, and after 8 months the pilot practices demonstrated a 94.3% compliance. BCMA utilization demonstrated a 40% decrease in self-reported medication administration errors during Q1 and Q2 2023 versus errors which occurred in the same period in 2022. Data collection is ongoing and continues to be analyzed by the project team. Epic development requests have been submitted to further improve Epic’s functionality with BCMA in the ambulatory care setting. After 6 months of BCMA the results were favorable, and the decision was made to expand BCMA to 2 additional pediatric practices for Fall 2023. Furthermore, BCMA is planned to expand throughout primary care practices in 2024. BCMA implementation has successfully decreased medication administration events and team member survey results indicate there was overall satisfaction with BCMA.
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: A standardized orientation process, or orientation bundle, is needed to engage new employees and make their transition period most meaningful. Evidence supports that following a competency-based orientation (CBO) and focusing on the employee's introduction to the clinic can lead to increased nurse retention and confidence. Literature suggests that including feedback from nurse mentorship can lead to increased productivity, better safety records, and higher patient satisfaction scores. As addressed in Symmerman et al., (2017), it was important to create an orientation bundle tailored to fit specific needs of a newly opened endoscopy clinic.
Description: In retrospect of previous onboarding orientation experiences, a small group of endoscopy nurses organized and worked on the development of an orientation bundle model for new nurses at the local endoscopy unit. As a result, the orientation bundle was created and implemented into practice in May 2023. Research was also conducted to assess creative and effective ideas to help redesign the current orientation process. Prior to project implementation, endoscopy nurses previously were given a general ambulatory care nursing orientation packet to complete with a preceptor. The new orientation forms include an orientation checklist, an interactive scavenger hunt, physician feedback, and a roadmap that guides new hires from the beginning of orientation to completion. All materials were created using an integrative approach. The bundle was created with the intent to limit the required amount of necessary paperwork material.
Evaluation/outcome: The new orientation bundle is currently being used and evaluated to guide new onboarding nurses and has yielded positive results such as increased confidence and readiness to practice independently. Prior to starting this project, staff were dissatisfied with their orientation onboarding process. After using a multidisciplinary approach to gather physician feedback and re-developing the orientation materials, two nurses were satisfied with their onboarding process.
Since its original implementation, the orientation bundle has been introduced at one additional endoscopy clinic. Upon completion of a new nurses’ journey through the orientation roadmap, orientees from both sites received a post-survey. The survey consisted of nine evaluative questions on a Likert scale from 1-5, four open-ended questions, and two questions assessing education level and nursing experience. Two RNs from the original implementation site completed the survey, and three nurses from the shared site completed surveys after their orientation. 100% of these nurses felt prepared and ready to begin safely on the unit. Survey results from the two clinic sites revealed that new hires can experience similar or varied orientation experiences. Orientation bundles oftentimes have to be changed to meet unit-specific needs.
Description: In retrospect of previous onboarding orientation experiences, a small group of endoscopy nurses organized and worked on the development of an orientation bundle model for new nurses at the local endoscopy unit. As a result, the orientation bundle was created and implemented into practice in May 2023. Research was also conducted to assess creative and effective ideas to help redesign the current orientation process. Prior to project implementation, endoscopy nurses previously were given a general ambulatory care nursing orientation packet to complete with a preceptor. The new orientation forms include an orientation checklist, an interactive scavenger hunt, physician feedback, and a roadmap that guides new hires from the beginning of orientation to completion. All materials were created using an integrative approach. The bundle was created with the intent to limit the required amount of necessary paperwork material.
Evaluation/outcome: The new orientation bundle is currently being used and evaluated to guide new onboarding nurses and has yielded positive results such as increased confidence and readiness to practice independently. Prior to starting this project, staff were dissatisfied with their orientation onboarding process. After using a multidisciplinary approach to gather physician feedback and re-developing the orientation materials, two nurses were satisfied with their onboarding process.
Since its original implementation, the orientation bundle has been introduced at one additional endoscopy clinic. Upon completion of a new nurses’ journey through the orientation roadmap, orientees from both sites received a post-survey. The survey consisted of nine evaluative questions on a Likert scale from 1-5, four open-ended questions, and two questions assessing education level and nursing experience. Two RNs from the original implementation site completed the survey, and three nurses from the shared site completed surveys after their orientation. 100% of these nurses felt prepared and ready to begin safely on the unit. Survey results from the two clinic sites revealed that new hires can experience similar or varied orientation experiences. Orientation bundles oftentimes have to be changed to meet unit-specific needs.
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:
evidence-based practice
clinical practice guidelines
suicide risk assessment
suicide risk management
Updated: 03/28/24
Purpose: Suicide has a significant impact on the United States effecting both veterans and the general population with a rate of 23.3 suicides per 100,000 veterans and 12.6 suicides per 100,000 non-veteran adults. Ambulatory care nurses (ACNs) care for veterans in all care settings since more than half of eligible veterans receive their care outside of the VHA. ACNs play a pivotal role in providing access to high-quality evidence-based care for suicidal patients. However, many ACNs have limited knowledge about evidence-based screening, evaluation, and treatment for suicidal patients. The use of the clinical practice guidelines (CPG) for patients at risk for suicide will assist ACNs to provide the best care for patients. CPGs are evidence-based recommendations intended to optimize the care of patients with specific conditions. CPGs developed by the VA and Department of Defense (DoD) are relevant to the care of veterans and non-veterans and are available in the public domain. This poster highlights CPG recommendations for the management of patients at risk for suicide to improve knowledge of evidence-based screening and treatments, reduce practice variation, and improve patient outcomes.
Review of literature: The VA/DoD evidence-based practice work group (EBPWG) convened a joint VA/DoD guideline development effort spearheaded by an interdisciplinary panel of practicing clinician experts. The guideline work group conformed to the Institute of Medicine's tenets for trustworthy guidelines. The guideline work group developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature. A total of 190 publications were reviewed by the guideline work group members and supported the development of 21 practice recommendations. The CPG recommendations are based on a systematic review of the scientific evidence, a weighing of the benefits and harms of interventions, consideration of what is known about patient values and preferences, and consideration of the applicability of the evidence across demographic groups and settings.
Summary of the innovation or practice: The risk for suicide CPG is intended to promote evidence-based screening and management of suicidal patients, and thereby improve patient’s clinical outcomes. The CPG is designed to assist primary care and mental health clinicians and specialists in screening patients for suicide risk, determination of appropriate treatment, and delivery of individualized interventions with a focus on mental health recovery. The poster will convey information in a visually appealing color scheme that enhances the readability of the poster. The design will be simple and easy to follow, highlighting the most important information and key concepts from the assessment and management of patients at risk for suicide CPG. Algorithms and charts will be incorporated to illustrate the data and recommendations.
Implications for ambulatory care nurses: ACNs play a pivotal role in providing high-quality health care to patients, including veterans. Attending this poster session will assist the practicing ACNs in understanding the evidence-based process used to develop the VA/DoD Assessment and management of patients at risk for suicide CPG. Additionally, participants will understand the importance and clinical impact of delivering evidence-based pharmacological and non-pharmacological interventions to individuals at risk for suicide.
Review of literature: The VA/DoD evidence-based practice work group (EBPWG) convened a joint VA/DoD guideline development effort spearheaded by an interdisciplinary panel of practicing clinician experts. The guideline work group conformed to the Institute of Medicine's tenets for trustworthy guidelines. The guideline work group developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature. A total of 190 publications were reviewed by the guideline work group members and supported the development of 21 practice recommendations. The CPG recommendations are based on a systematic review of the scientific evidence, a weighing of the benefits and harms of interventions, consideration of what is known about patient values and preferences, and consideration of the applicability of the evidence across demographic groups and settings.
Summary of the innovation or practice: The risk for suicide CPG is intended to promote evidence-based screening and management of suicidal patients, and thereby improve patient’s clinical outcomes. The CPG is designed to assist primary care and mental health clinicians and specialists in screening patients for suicide risk, determination of appropriate treatment, and delivery of individualized interventions with a focus on mental health recovery. The poster will convey information in a visually appealing color scheme that enhances the readability of the poster. The design will be simple and easy to follow, highlighting the most important information and key concepts from the assessment and management of patients at risk for suicide CPG. Algorithms and charts will be incorporated to illustrate the data and recommendations.
Implications for ambulatory care nurses: ACNs play a pivotal role in providing high-quality health care to patients, including veterans. Attending this poster session will assist the practicing ACNs in understanding the evidence-based process used to develop the VA/DoD Assessment and management of patients at risk for suicide CPG. Additionally, participants will understand the importance and clinical impact of delivering evidence-based pharmacological and non-pharmacological interventions to individuals at risk for suicide.
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: According to the National Institutes of Health (NIH), anal cancer has become a concerning issue with an estimated 10,000 new cases and 1,870 annual deaths in the United States. However, medical providers often overlook the significance of anal cancer, particularly in high-risk populations like gay men, bisexual men, and transgender women. In 2022, the ANal Cancer/HSIL Outcomes Research (ANCHOR) study by Lee et al. revealed a high incidence rate of pre-anal cancer (14.1%) in these groups, emphasizing the need for early screening and prevention. This nurse-led project aims to establish standardized clinical protocols and care pathways to enhance anal cancer screening, particularly in HIV/STD clinics, and bridge the healthcare gap for equity and equality.
Significance: Gay men, bisexual men, and transgender women face disparities in cancer screening and sexual health prevention. The absence of specific guidelines from the Centers for Disease Control and Prevention (CDC) for these groups highlights the importance of this nurse-led project, which focuses on implementing standardized anal cancer screening and testing in HIV/STD clinics. The primary goal is to improve the quality of care and outcomes for high-risk populations by introducing anal pap smears into ambulatory care. This project seeks to facilitate early screening, testing, and referrals to specialty oncology care for gay men, bisexual men, and transgender women. The nurse-led project hypothesizes that implementing rectal cancer screening and testing will result in over 30% of pre-cancer findings within a year of implementation, thereby increasing testing rates, reducing wait times for treatment, lowering access barriers, and improving early diagnosis.
Methods: This nurse-led project employs the plan-do-study-act (PDSA) framework. In phase one, an interdisciplinary team developed an anal pap screening tool for targeted patients. Phase two involved creating clinical protocols and educational materials for anal pap screening tool utilization. All patients receive screening questionnaires before their appointments, with positive results triggering anal pap smear orders. Phases three and four consist of audits to collect data and implement interventions to improve the protocol.
Results: From November 2022 to September 2023, 719 patients completed anal pap screening questionnaires out of a total of 1,486. The response rate was 48%, with 109 eligible for anal pap smear tests. Among them, 38 tested positive, resulting in a 35% positivity rate. Post-implementation showed a fivefold increase in anal pap smear performance compared to pre-implementation. Abnormal cells included ASCUS, LSIL, and HSIL, with referrals made for further evaluation. Data collection continues until November 2023.
Conclusions: Utilizing the PDSA framework, the RN-led rectal cancer screening and testing protocol shows promise in improving the health outcomes of high-risk populations. The nurse-led project is set to continue its PDSA cycles in 2023, expanding standardized sexual health care for these populations. Key success factors include the adoption of opt-out screening questionnaires, stakeholder involvement, and effective education and training. This project aims to inspire primary care settings to adopt these strategies and contribute to closing gaps in equality, equity, and inclusion in health care.
Significance: Gay men, bisexual men, and transgender women face disparities in cancer screening and sexual health prevention. The absence of specific guidelines from the Centers for Disease Control and Prevention (CDC) for these groups highlights the importance of this nurse-led project, which focuses on implementing standardized anal cancer screening and testing in HIV/STD clinics. The primary goal is to improve the quality of care and outcomes for high-risk populations by introducing anal pap smears into ambulatory care. This project seeks to facilitate early screening, testing, and referrals to specialty oncology care for gay men, bisexual men, and transgender women. The nurse-led project hypothesizes that implementing rectal cancer screening and testing will result in over 30% of pre-cancer findings within a year of implementation, thereby increasing testing rates, reducing wait times for treatment, lowering access barriers, and improving early diagnosis.
Methods: This nurse-led project employs the plan-do-study-act (PDSA) framework. In phase one, an interdisciplinary team developed an anal pap screening tool for targeted patients. Phase two involved creating clinical protocols and educational materials for anal pap screening tool utilization. All patients receive screening questionnaires before their appointments, with positive results triggering anal pap smear orders. Phases three and four consist of audits to collect data and implement interventions to improve the protocol.
Results: From November 2022 to September 2023, 719 patients completed anal pap screening questionnaires out of a total of 1,486. The response rate was 48%, with 109 eligible for anal pap smear tests. Among them, 38 tested positive, resulting in a 35% positivity rate. Post-implementation showed a fivefold increase in anal pap smear performance compared to pre-implementation. Abnormal cells included ASCUS, LSIL, and HSIL, with referrals made for further evaluation. Data collection continues until November 2023.
Conclusions: Utilizing the PDSA framework, the RN-led rectal cancer screening and testing protocol shows promise in improving the health outcomes of high-risk populations. The nurse-led project is set to continue its PDSA cycles in 2023, expanding standardized sexual health care for these populations. Key success factors include the adoption of opt-out screening questionnaires, stakeholder involvement, and effective education and training. This project aims to inspire primary care settings to adopt these strategies and contribute to closing gaps in equality, equity, and inclusion in health 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.
Tags:
standardization
quality and safety
documentation burden reduction
clinic intake
ambulatory care requirements
Updated: 03/07/24
In a recent visit from The Joint Commission, it was evident that there was not a clearly defined minimum expectation for documentation of clinic intake in ambulatory care spaces across our institution, which conducts over 3 million outpatient visits yearly (including pediatrics and regional facilities). Before our change, different specialty areas prioritized different clinic intake elements for their patient populations, and there was even variation between staff members in the same department. This resulted in an inconsistent experience for our patients and confusion for our staff and providers. To address this issue, nursing informatics services worked closely with quality and safety, as well as nursing and provider executive leaders to define minimum standards and develop a tool for all ambulatory care spaces to help guide staff through those questions that formed the minimum standards. In doing so, we helped ensure a consistent experience across all ambulatory care areas for our patients, families, staff, and clinicians. Our change also helped ensure regulatory compliance and enhanced the safety and efficacy of clinic intake.
Using a PDSA (plan-do-study-act) cycle, nursing informatics services worked with the eStar ambulatory care analyst team to develop a “checklist” that displays in the intake activity within eStar. It displays the organizational minimum requirements, and once a staff member addresses that item at the correct interval – for example, an annual item addressed within the last 365 days – it is checked off the list. This also helped reduce the number of questions asked to patients by crossing encounter departments. For example, if you had been asked in primary care about your advanced directive last month, you would not be asked again in ENT today.
We launched this project in all ambulatory care areas at once! It was such an intuitive design that staff required little at-the-elbow support. The checklist helped guide them through the minimum requirements as designed.
In a second phase of our project, we allowed patients to answer most of the required intake elements via our patient portal system. In doing so, we helped reduce staff documentation burden. This was integrated with our previous checklist work, and many times the patient’s checklist would be completed before they ever sat down in the clinic room for intake.
Overall, we achieved the outcome of defining the core minimum intake requirements and developing a tool to encourage adherence to the new standards. Also, staff reports an increased ability to determine the required documentation for ambulatory care encounters since the change was implemented. Prior to the change, 33% of polled staff reported that it was “very easy” to determine required documentation for clinic intake. After implementation, that number rose to 51%. Perceived documentation time was also reduced. Before our change, 20% of staff felt that they could complete clinic intake in less than 5 minutes. Afterward, 27% reported being able to complete the process in less than 5 minutes.
Through a multi-team approach, we improved nursing workflow and patient satisfaction by helping define minimum documentation standards that meet regulatory requirements and satisfy quality standards.
Using a PDSA (plan-do-study-act) cycle, nursing informatics services worked with the eStar ambulatory care analyst team to develop a “checklist” that displays in the intake activity within eStar. It displays the organizational minimum requirements, and once a staff member addresses that item at the correct interval – for example, an annual item addressed within the last 365 days – it is checked off the list. This also helped reduce the number of questions asked to patients by crossing encounter departments. For example, if you had been asked in primary care about your advanced directive last month, you would not be asked again in ENT today.
We launched this project in all ambulatory care areas at once! It was such an intuitive design that staff required little at-the-elbow support. The checklist helped guide them through the minimum requirements as designed.
In a second phase of our project, we allowed patients to answer most of the required intake elements via our patient portal system. In doing so, we helped reduce staff documentation burden. This was integrated with our previous checklist work, and many times the patient’s checklist would be completed before they ever sat down in the clinic room for intake.
Overall, we achieved the outcome of defining the core minimum intake requirements and developing a tool to encourage adherence to the new standards. Also, staff reports an increased ability to determine the required documentation for ambulatory care encounters since the change was implemented. Prior to the change, 33% of polled staff reported that it was “very easy” to determine required documentation for clinic intake. After implementation, that number rose to 51%. Perceived documentation time was also reduced. Before our change, 20% of staff felt that they could complete clinic intake in less than 5 minutes. Afterward, 27% reported being able to complete the process in less than 5 minutes.
Through a multi-team approach, we improved nursing workflow and patient satisfaction by helping define minimum documentation standards that meet regulatory requirements and satisfy quality standards.
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
Sickle cell anemia is a complex disease process that contributes to a variety of medical complications related to hemolytic anemia and vaso-occlusion, causing significant health consequences from tissue ischemia and infarction. Depression and anxiety have been identified as common comorbidities contributing to an increase in healthcare utilization and costs. A diagnosis of major depression is also linked to elevated frequency and severity of pain. In the sickle cell disease (SCD) population, opioids are utilized as the primary treatment for the management of moderate-severe pain associated with their disease. Opioid use, however, has been linked to greater incidence of both depression and anxiety. Additionally, it has been identified that individuals with a diagnosis of both depression and chronic pain are more likely to use opioids even when their pain is controlled.
The US Preventive Service Task Force (USPTSF), CDC, and The American Society of Hematology (ASH) 2020 guidelines for sickle cell disease (SCD) recommend routine screening for depression and anxiety to assess patients for the presence of psychosocial health complications to identify individuals who may require social work, psychiatric, or case management referral. In the setting of an inner-city university hospital, there is no current policy endorsing routine depression and anxiety screenings within the sickle cell population experiencing vaso-occlusive event/episode (VOE).
This quality improvement project aims to increase in the number of patients screened for anxiety and depression and increase in the number of patients who screen positive and agree to mental health referral utilizing the PHQ-9 and GAD-7 screening tools. A team of six nurse practitioners will attend an educational PowerPoint session supporting the use of these screening tools to identify depression and anxiety as well as evidence describing the effects of SCD and comorbid mental health disorders. A pre- and post-screening intervention chart review will be conducted to compare outcomes, specifically if referrals were agreed to and placed. During this quality improvement (QI) project, data will be collected at weekly intervals for three months starting the day of project implementation and three months after the mental health screening intervention has been completed, for a total of six months. Scores will be calculated comparing pre- and post-intervention results, specifically the number of mental health screenings performed. Additionally, the number of mental health referrals placed will be counted. Anticipated outcomes include a statistically significant increase the number of patients screened for anxiety and depression utilizing the PHQ-9 and GAD-7 screening tools and an increase in the number of patients who agree to referral for the diagnosis if they test positive.
The US Preventive Service Task Force (USPTSF), CDC, and The American Society of Hematology (ASH) 2020 guidelines for sickle cell disease (SCD) recommend routine screening for depression and anxiety to assess patients for the presence of psychosocial health complications to identify individuals who may require social work, psychiatric, or case management referral. In the setting of an inner-city university hospital, there is no current policy endorsing routine depression and anxiety screenings within the sickle cell population experiencing vaso-occlusive event/episode (VOE).
This quality improvement project aims to increase in the number of patients screened for anxiety and depression and increase in the number of patients who screen positive and agree to mental health referral utilizing the PHQ-9 and GAD-7 screening tools. A team of six nurse practitioners will attend an educational PowerPoint session supporting the use of these screening tools to identify depression and anxiety as well as evidence describing the effects of SCD and comorbid mental health disorders. A pre- and post-screening intervention chart review will be conducted to compare outcomes, specifically if referrals were agreed to and placed. During this quality improvement (QI) project, data will be collected at weekly intervals for three months starting the day of project implementation and three months after the mental health screening intervention has been completed, for a total of six months. Scores will be calculated comparing pre- and post-intervention results, specifically the number of mental health screenings performed. Additionally, the number of mental health referrals placed will be counted. Anticipated outcomes include a statistically significant increase the number of patients screened for anxiety and depression utilizing the PHQ-9 and GAD-7 screening tools and an increase in the number of patients who agree to referral for the diagnosis if they test positive.
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.
