UPMC St. Margaret 2011/2012. Illuminating Our Journey to Distinction. 815 Freeport Road Pittsburgh, PA UPMCStMargaret.com

Transcription

1 Nursing Annual Report 2011/2012 Illuminating Our Journey to Distinction 815 Freeport Road Pittsburgh, PA UPMCStMargaret.com

2 Table of Contents 1 Welcome Magnet Model 2 Getting to Know 3 Transformational Leadership Stroke Program Flex Monitor Discontinuation 5 Structural Empowerment Shared Governance Model Improved Throughput WHO Surgical Safety Checklist 7 Exemplary Professional Practice Nurse Satisfaction Data COPD Program CAUTI Initiative 9 New Knowledge, Innovations, and Improvements Research Activities Rehab Efficiency Study 10 Nursing Accomplishments Current Professional Contributions Honors and Awards Publications Degrees Earned Professional Organizations Professional Presentations Podium Presentations Certifications Welcome from Mary Barkhymer Chief Nursing Officer and Vice President, Patient Care Services We are Nursing! During the past year, our nurses have provided patient care to more than 11,000 patients and their family members. We have focused our efforts on continuing our Magnet journey to recertification and have embraced the challenges of the changing health care environment, from pay-to-performance to instituting Just Culture awareness. We have updated our Nursing Division Strategic Plan to include corporate priorities and realigned it with Magnet principles for clarity. We are an innovative organization. We are making major improvements in our Emergency Department patient flow through a multidisciplinary throughput project. The result of this program is better care for our patients and faster transitions out of the hospital. We have instituted a number of programs to address noise at night and patient falls, focused on improving these core measures and enhancing patient care. We are a learning organization. By supporting nurses in the pursuit of advanced degrees and certification, My Nursing Career Projects, and continuing the My Nursing Residency program, we are focusing on evidence-based projects. We instituted the Nursing Research Fellowship in an effort to support nurses who are interested in changing nursing practice and looking at patient care in innovative ways. We are a changing organization. Nurses are working on all levels every day, every shift to make positive changes happen. Efforts are focused on improving patient outcomes, increasing patient satisfaction, and enhancing nursing satisfaction. It aligns with our Your Care. Our Commitment. theme which promises the highest level of patient services always striving to exceed tangible patient outcomes. We are leaders in patient care and nursing science. With strength from our shared governance councils and nursing clinical directors, nurses are clinical experts functioning as leaders on multidisciplinary teams to make a difference in the patients care. As we look ahead, we will be challenged to sustain enhanced quality care in the top quartiles of performance in all measures and at all levels. Together, we are confident that we will meet the challenges of today and tomorrow to benefit our patients, our colleagues, and the organization. I invite you to read about our journey and appreciate the breadth of nursing activity at UPMC St. Margaret. Magnet Model

3 Getting to Know Situated on a 21-acre campus near Aspinwall, is a 249-bed acute care and accredited teaching hospital that has been granted American Nurses Credentialing Center (ANCC) Magnet Recognition, the highest international recognition for nursing excellence and leadership. With renewed dedication to more than 250,000 residents of northeastern Allegheny County and the Alle-Kiski Valley, provides residents convenient access to the area s finest physicians and health care services. is recognized for excellent performance and patient-centered initiatives. received the American Heart Association/American Stroke Association s Get With The Guidelines Stroke Gold Plus Performance Achievement Award, which recognizes the hospital s commitment and success in implementing excellent care for stroke patients, according to evidence-based guidelines. Role Changes to Improve Workflow, an initiative developed at the Lawrenceville Family Health Center, earned distinction by the Joint Commission Leading Practice Library. The initiative was created to eliminate lab errors, improve patient flow, and increase the turnover of patient rooms. The St. Margaret School of Nursing received formal notification from the National League for Nursing Accrediting Commission (NLNAC) granting the school continuing accreditation for the maximum period of eight years. s three family health centers, located in Bloomfield-Garfield, New Kensington, and Lawrenceville, have been recognized by the National Committee for Quality Assurance (NCQA) as a Physician Practice Connections Patient-Centered Medical Home (PPC -PCMH ). The health centers received Level 3 recognition the highest level designated by the NCQA for using systematic, patient-centered, and coordinated care management processes. Illuminating our Journey to Distinction 2

4 Transformational Leadership Stroke Program has established an extensive Stroke Program to support our Primary Stroke Certification. The Interdisciplinary Stroke Team, comprised of physicians, nurses, and ancillary staff, works to provide excellent stroke care to our patients. Ongoing education is provided to hospital staff to ensure quality care. Education is offered to nursing, patients, and ancillary staff in a variety of methods to support their learning needs. Over the past year, education has been provided to all levels of hospital staff to enhance our stroke patient care. also is given to nursing staff. We have the ability to use telemedicine to provide 24/7 access to neurology. Charting on stroke patients and patient education are reviewed during the stroke orientation presentation. Providing new hires with a stroke review was implemented in April Nurses are required to complete an annual competency which provides stroke updates, a review of the program, and care of stroke patients monthly. Stroke-related evidence-based literature and questions also are provided to staff on stroke units. There are eight stroke quality measures which we provide when caring for the stroke/tia population. Our nursing staff, as well as ancillary staff, are provided with information needed to initiate stroke care. UPMC St. Margaret has order sets in place as protocols to ensure that proper care is initiated in a timely manner. Monitoring of the measures is done monthly by using the Get with the Guidelines Program. Staff receive feedback and education on the initiatives. The Joint Commission Primary Stroke Center Core Measures 100% n 2010 n 2011 Nursing staff is provided with stroke education at the new-hire orientation program on the variety of strokes that may occur and what interventions are used for each. Education includes a review of the signs and symptoms, risk factors, and what to do if a patient is suffering from a new stroke. Nurses are highly educated in the process of calling a Condition C, the code used when a patient may be suffering from a stroke. A brief introduction on the use of telemedicine 98% 96% 94% 92% 90% 88% 86% 84% 82% VTE Anti- Anticoagulants t-pa Initated Antithrombotic Statin Stroke Assessed for Prophylaxis by thrombotics at Discharge Within 3 Hours Therapy by Medication at Education Rehabilitation Hospital Day 2 at Discharge if A-Fib/Flutter of Last Known Hospital Day 2 Discharge Well 3 UPMC ST. MARGARET NURSING REPORT

5 Our stroke/tia patients are given stroke education covering stroke signs and symptoms, how to activate EMS, risk factors, medications, diagnostic procedures, and the importance of follow-up care after discharge to home. When speaking with our patients and their family members, we incorporate individual learning needs by using handouts, books, and verbal repetition. After discharge, follow-up phone calls are made to patients to review what they have learned while in the hospital. Our goal is the use of the teach back method. We teach patients while they are in the hospital, then during the follow-up phone call we ask them to provide us with a review with little or no prompting of answers. The majority of patients have an adequate understanding of the information they were taught. Although the patient may have suffered from a stroke/tia, we enforce prevention as the key to decrease recurrence of another episode. Flex Monitor Discontinuation Process Nursing leadership established a process to prevent inpatient admissions from being held in the Emergency Department or other patient care areas due to lack of flex monitor availability. Meetings were held with key physician leaders to establish criteria for flex monitor discontinuation and for approval of final policy changes. In addition, Gina Koch, MSN, RN, CMSRN, performed a research study that involved a retrospective chart review of 700 flex monitor patients to assess characteristics of patients who developed a new arrhythmia requiring treatment after a 48-hour period of being arrhythmia-free. Patients who were ordered a flex on admission, were not admitted with an arrhythmia or chest pain, were not comfort measures only or transferred to a higher level of care during their stay and were on a flex monitor greater than 48 hours were included in the review. Outcomes indicated a 45 percent reduction in the number of shifts without a flex monitor available from September 2011 through January Unit 6B Call Back Results 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec Education 100% 100% 100% 100% 100% 100% 100% 100% 100% 84% 100% 75% Anti-Coag Meds 100% 91% 100% 100% 100% 100% 100% 100% 100% 92% 100% 100% Cholesterol Meds 100% 86% 100% 100% 90% 100% 100% 88% 100% 100% 100% 100% Illuminating our Journey to Distinction 4

6 Structural Empowerment UPMC ST. MARGARET NURSING DIVISION SHARED GOVERNANCE MODEL NURSING DIVISION LEADERSHIP COUNCIL NURSING PROFESSIONAL NURSING PROFESSIONAL EDUCATION, NURSING CLINICAL ADVANCED PRACTICE QUALITY DEVELOPMENT RESEARCH AND OPERATIONS PRACTICE CLINICIAN COUNCIL COUNCIL COUNCIL EBP COUNCIL COUNCIL COUNCIL COUNCIL UNIT BASED PROFESSIONAL PRACTICE COUNCIL Improved Throughput Emergency Department (ED) throughput for patients requiring hospital admission is dependent on the efficiency of the flow of patients within inpatient units. Bottlenecks of admitted patients that cannot be moved in a timely manner from the ED to their inpatient rooms impacts the ED discharge patient length of stay by keeping ED rooms full with inpatients awaiting inpatient room assignment. Nurses have positively impacted patient throughput by implementing process changes. Inpatient nurses huddle each morning with interdisciplinary care team members to identify and prioritize patient needs for the day. Communication occurs with ancillary testing departments to prioritize patient tests that will reduce length of stay if completed earlier in the day. Predicted discharges by 2 p.m. and totals for the day are shared at the daily throughput meeting attended by nursing representatives from each inpatient unit, Emergency Department, Surgical Services, Care Management, and Environmental Services. These changes reduced wait times in the ED for admitted patients by 80 minutes. In addition to these changes, the nurses from the ED worked with interdisciplinary ED team members to develop and implement a work flow change within the ED to further decrease length of stay. The 26-bed ED was divided into smaller work zones consisting of blocks of rooms. Small teams of staff are assigned to each zone, creating improved efficiency and increased patient interaction with staff which has resulted in reduced wait times and improved patient satisfaction scores. 5 UPMC ST. MARGARET NURSING REPORT

7 Emergency Department Press Ganey Overall Mean Score Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Emergency Department Average Daily Boarder Minutes Boarder Minutes = Time from Ready to Admit to Admission minus 60 minutes Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Inpatient Emergency Department LOS (median time in minutes) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun WHO Surgical Safety Checklist The WHO Surgical Safety Checklist was implemented to improve surgical care by preventing or reducing adverse surgical outcomes. This checklist utilizes a combination of the safety requirements of the Joint Commission, the Association of PeriOperative Registered Nurses, and the World Health Organization. UPMC partnered with the Pennsylvania Patient Safety Authority in their wrong-site surgery prevention program. At an eight-hour workshop, surgeons, anesthesiologists, operating room nurses, and senior leadership were given the opportunity to further refine the checklist. Checklist compliance reports are captured electronically for 100 percent of procedures. Reports are shared monthly with operating room leadership. In addition, 30 real-time observations of our operating room staff using the checklist were completed by each surgical area. Revisions were made to wording in order to clarify elements based on these results. Implemented in April 2011, each OR area routinely completes ten observations. UPMC also established a Good Catch Hotline for staff to report and share those events that were identified during the safety checklist process. These good catches are shared with staff to be used as learning tools to prevent future occurrences. Karen Zanin RN, CNOR, IS Specialist for the OR, was designated as checklist coordinator. Since her designation, she has guided this process from early 2009 to the present. In conclusion, use of the surgical safety checklist has had a positive impact on preventing surgical adverse events. Since August 2010, there have been zero wrong site, wrong patient, or wrong procedure surgeries performed in operating rooms. Illuminating our Journey to Distinction 6

8 Exemplary Professional Practice Nurse Satisfaction Data Nurse satisfaction is measured and analyzed by nursing leadership and staff to identify opportunities to further enhance patient care, the work environment, nurse satisfaction, and engagement. As the CNO of UPMC St. Margaret, Mary Barkhymer, MSN, RN, CNOR, partners with nursing leaders and the Professional Practice Council (PPC) to develop an annual nursing strategic plan including targeted quality improvement plans. As part of this process, nursing satisfaction scores are reviewed for opportunities for improvement. has utilized the National Database of Nursing Quality Indicators (NDNQI) Nursing Satisfaction Survey. Participation of registered nurses has ranged from 94 to 96 percent, demonstrating the value our nurses have placed on this process and accurately reflects the voice of nursing at. This feedback has proven to be crucial when examining nursing issues and exemplifies that staff know their opinions will be heard. The process for analyzing this data and involving direct care nurses in making changes based on those results is through the use of the SOAR model (strengths, opportunities, aspirations, and results). The CNO and the PPC analyze each opportunity for improvement by individually focusing on strengths, rather than weaknesses, and using the strengths as assets for improvement initiatives. The SOAR model is an appreciative inquiry model that gives voice to employees in the design of the nursing strategic plan for the hospital and their respective areas. Action plans and timelines are then set into place to address the top areas of opportunity NDNQI Nurse Satisfaction Survey Results Tasks RN-RN RN-MD Decision- Autonomy Professional Pay Professional Nursing Nursing Interaction Interaction Making Status Development Management Administration NDNQI Magnet NDNQI Bedsize NDNQI Teaching Hospital NDNQI Nurse Satisfaction Survey Results Tasks RN-RN RN-MD Decision- Autonomy Professional Pay Professional Nursing Nursing Interaction Interaction Making Status Development Management Administration NDNQI Magnet NDNQI Bedsize NDNQI Teaching Hospital

9 COPD Program Earns Gold Fine Award was the recipient of the 2011 Gold Award for Sustained Excellence through the fourth annual Fine Award for Teamwork Excellence in Health Care. The hospital successfully reduced readmissions for patients suffering from chronic obstructive pulmonary disease (COPD), improving patient care processes and clinical outcomes. s submission for the Fine Award, Sustain the Gain: COPD Readmission Reduction, was provided by the hospital s Care Management/Quality Department with the goal of reducing readmissions from COPD. With the commitment and support of its hospital leadership and medical staff, s multidisciplinary team achieved a dramatic 36.9 percent decrease in COPD readmissions over the past two years resulting in positive results for patients and a reduction in costs. The Fine Award, sponsored by The Fine Foundation, Jewish Healthcare Foundation, and Pittsburgh Regional Health Initiative, honors high-performing health care teams in western Pennsylvania whose achievement in decreasing waste, error, or poor care is renowned. The award encourages teamwork and recognizes those who have made breakthroughs in patient safety and quality care. COPD Readmission/Discharge Comparison January 2008-December % 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 12% 6.7% 8.6% /2010 Baseline Year 1 Year 2 Average Years 1 and 2 Readmissions % Discharges ,056 Combined Percent 12.0% 6.7% 8.6% 7.6% Percent Change -44.4% -28.5% -36.9% Catheter Associated Urinary Tract Infection (CAUTI) Initiative The Catheter Associated Urinary Tract Infection (CAUTI) Prevention Initiative was implemented at with the focus on reducing urinary catheter (Foley ) device utilization to reduce CAUTIs by 10 percent, using the previous 12 months as baseline data, through the initiation of UPMC and hospital-based initiatives. The Daily Foley Catheter Necessity Report is reviewed each morning by the Unit Resource Nurse. Catheter necessity is evaluated with the bedside nurse and physician to determine need and to expedite removal. This report also is utilized to assess the use of catheter securement devices daily along with Foleys that were placed on order. Focused efforts are placed on back-to-basics catheter care with education through mandatory ulearn for all levels of nursing staff. The competency covers urinary catheter necessity, insertion, post-insertion care, removal, alternatives, and the nurse-driven removal protocol. The Foley removal protocol is connected to the majority of catheter orders. Staff have the ability to select no to the protocol if he/she wishes to override the time of catheter removal. Nurses continue to assess the patient every shift for possible removal of catheters which are indicated by nurses as protocol. An algorithm was developed in conjunction with the protocol to help with managing urine output once the catheter is removed. A Necessity Report is printed on every nursing unit with information on patients with an indwelling urinary catheter. In order to improve compliance with patients who have indwelling urinary catheters placed without orders, an electronic alert was created in erecord. Reports are autogenerated to the hospital president, CNO, Quality director, and CAUTI champions. The report contains a red/yellow/green dashboard of device utilization with a goal of 10 percent reduction from the prior year. These include hospital and individual unit data regarding infection rate, number of infections, and urinary catheter device utilization. Outcomes for these various initiatives are positive. In calendar year 2010, 31 CAUTIs were identified resulting in a rate of 1.63/1,000 catheter days. In 2011, we saw a significant decrease only 15 CAUTIs were identifed resulting in a rate of.83/1,000 catheter days an approxmiate 50 percent reduction since the implementation of the CAUTI initiative. Illuminating our Journey to Distinction 8

10 New Knowledge, Innovations, and Improvements Nurse-Driven Research Activities Nurses throughout engage in research and apply evidence-based practice to their daily work and strive to deliver optimal care outcomes. To ensure that bedside nurses are engaged in evidence-based practice and nurse-driven research, the Nursing Education, Research, and Evidence-Based Practice Council supports several nursing research initiatives. In pursuit of new knowledge, our nurses have led and/or participated in research studies as the principal investigator, co-investigator, or investigator. As these nurses conduct research and strive to implement best practices for their patients, it is important to share study results with their UPMC colleagues. As such, hosts an annual Clinical Research Forum sponsored by the Nursing Education, Research, and Evidence-Based Practice Council. This forum provides an opportunity for both novice and experienced nurse researchers to present and discuss research findings through podium and poster presentations. The theme of this year s forum was Generating New Knowledge and Innovation Through Nurse-Driven Research. The forum provided an opportunity for 80 nurses within the UPMC system to network, dialogue, and discuss each other s work and to generate new research ideas. Another way we promote new knowledge and innovation is through the Hot Topics series. sponsored a Nursing Innovation Summit in March 2012 that showcased and shared innovative ideas and insights in nursing education, leadership, clinical practice, research, and technology. The goal of the Summit was to draw attention to innovative ideas in nursing and to foster professional discussion and collaboration among nurses at all levels. Podium Presentation abstracts were selected through a blinded review process. Ten presenters were selected and each was allotted 15 minutes to present. There was a panel question-and-answer session at the conclusion of the program to further discuss nursing research. Hot Topics will continue to be offered throughout the year. To continue to promote, develop, and expand nursing research at, the Nursing Research Fellowship was developed to assist bedside nurses to transform their bedside ideas into research projects. After an application and review process, research fellows were accepted into the program. Currently, four bedside nurses are involved in nurse-driven research at various stages of the process and are included in the listing below. Each research fellow receives eight hours per month of dedicated time to participate in research activities. is committed to improving patient care and outcomes through nurse-driven research. These nurses contributed to the future of nursing by leading research projects in 2011 and 2012: Shawna Breghenti, BSN, RN Expanded Family Visitation in the Postanesthesia Care Unit (PACU) Doris Cavlovich, MSN, RN, CCRN The Experience of Workplace Violence by Student Nurses Gina DeFalco, MSN, RN Pre-licensure Students Perceived Importance of Concepts in Nursing Practice Angela Durci, RN Risk Factors for Pressure Ulcers in Total Hip and Knee Surgical Patients Mary Dee Fisher, DNP, RN, CPN A Comparison of Professional Value Development in Pre-licensure Nursing Students Lori Kelly, BSN, BS, RN, CEN Jennifer Drapas, MSN, BA, RN Improving Heart Failure Outcomes Lynne Kijowski, RN Ambulation Project Gina Koch, MSN, RN, CMSRN Stroke Caregiver Study Flex Monitor Discontinuation Deborah Y. Lewis, DNP(C), RN, CNE QSEN: Attitudes of Student Nurses and Faculty Related to Quality and Safety Michelle McClain, RN The Use of Sound Masking to Improve Patient Sleep and Daily Rest Michelle Regas, RN Effect of Nursing Education on Decreasing Smoking Prior to Physician Visits in an Outpatient Setting Judith Tinelli, MSN, RN, OC, CNL, CCRN Rehab Efficiency Study 9 UPMC ST. MARGARET NURSING REPORT

11 Rehab Efficiency Study An experimental-observational study was conducted on 94 patients on the hospital s rehab unit to evaluate the effectiveness of utilizing a medication nurse four mornings per week over a two-month period. No FTEs (full-time equivalents) were added, making it budget neutral. The premise was that adding a medication nurse for morning medication administration would positively impact patients on-time arrival to therapy appointments by decreasing current causes for late arrival, such as medication administration. The study resulted in no medication errors, as well as the elimination of the top two reasons for lateness medication administration and patients needing to use the bathroom. Overall Press Ganey Associates Inc. patient satisfaction scores rose from the 34th percentile to the 54th percentile during the study. The day shift nurse quality Press Ganey rating increased from the 21st percentile to the 45th percentile. The night shift rose from the 25th percentile to the 64th percentile. Availability of the nurses soared to the 57th percentile from the 9th percentile. Nursing Accomplishments 2011/2012 CurrenT professional Contributions Keith Baily, MSN, RN, CCRN Stroke Code Team: Self-Learning Module Abena-Yolanda Baskin, MSN, RN, CNOR Can You Hear Me Now: Nurses Voices Being Heard Bonnie Brannagan, RN, ONC Improving Pain Management Scores on 4B Donna Dzvonick, RN, ONC Nursing Care of the Patient with a Peripheral Nerve Block Julie Ann Farren, BSN, RN, CNOR Competencies Coordinator Susan Fenoglietto, BSN, RN, CMSRN Improving the Acute Rehabilitation Patients Discharge Process Patricia Hanselman, RN, CMSRN Best Practice for Post-Operative Vital Signs Using EBP Kim Holmes, BSN, RN, CMSRN Save Our Skin Education, Bedside Tool and Treatment Protocol Orthopedic Fall Champion Pam Jaecke, RN, CMS Medical Surgical Nursing Certification Champion Roberta Jones, BSN, RN, CNOR Getting the Word Out: Spreading the Word to Decrease Flash Sterilization in the Operating Room Facilitating Changing Practice Lynn Kijowski, BSN, RN, CMS Further Development of a Unit-Based Professional Practice on Unit 5B Mary Kochick, RN, CMSRN Development of a Nursing Orientation Manual for the Medical Unit at Karen Mains, RN, CMSRN The Right Time to Move Kathleen McKeag, RN, CRN Radiology Nursing A Certification Guideline Susan Ober, MSN, MBA, RN, CNOR Unit-Based Evidence-Based Policy Committee Roberta Olszewski, RN, CMSRN Care of the Neutropenic Patient in the Acute Care Setting Cynthia Paner, MSN, RN, CNOC Blood Clot Prevention in Cancer Patients Jerome Pettigrew, RN, CMSN Suctioning Competency Champion Brittany Pore, RN, CNOR Geriatric Fracture Program Trudy Praniewicz, BSN, RN, CCRN VA: Critical Event Margaret Runco, RN, ONC Surgical Care Improvement Project: SCIP Initiative with a Focus on VTE Champion for 4B Deborah Ryan, BSN, RN, CNOR Press Ganey Champion of the Surgical Services Division Heather Santillo, RN, CNOR CNOR Certification 3B Nurses who are Part of the Code Response Team through Initiation of Mock Code Performances Dawn Scrima, RN, CMS Use of Bedtime Snacks to Prevent Nocturnal Hypoglycemic Events Rhoda Shoaf, RN Noise Reduction in the ICU Shari Spangler, RN, CEN Department Communication and Activities Coordinator Nurse/ Physician Communication Liaison Rebecca Sproul, RN, CCRN Community Based Hypertension Education Kariane Stuebgen, RN, CCRN Implementation of NxStage- Continuous Renal Replacement Therapy in the ICU Virginia Wright, BSN, RN, CNOR Reintroduction of Journal Club at Harmar Kimberly Yurchick, RN, CCRN The Electrolyte Protocol: A Matter of Compliance Kimberly Hitrik, RN, CRRN NIH Stroke Scale Tina Mourra, BSN, RN, CEN ACLS and PALS Course Director Tara Schaff, BSN, RN Improving Confidence of ICU and (continued on page 11) Illuminating our Journey to Distinction 10

12 Honors and Awards Congratulations to these nurses who were recognized between January 2011 and June 2012 for their dedication to the nursing profession. Cameos of Caring Sponsored by the University of Pittsburgh School of Nursing, Cameos of Caring provides an opportunity to honor outstanding nurses for their dedication to quality patient care, increase public awareness of the nursing profession, and recruit a new generation of nurses. Awardees: Cameos of Caring Rosharon Price, RN Denise Koch, MSN, RN Cameos of Caring Award for Nurse Educators Gina DeFalco, MSN, RN Mary Dee Fisher, DNP, RN, CPN Cameos of Caring Advanced Practice Clinical Focus Tanya Hoebel, MSN, RN, CNML Cameos of Caring Advanced Practice Manager Focus Marjorie Jacobs, MSN, RN, ACM DAISY Award The DAISY Award recognizes the extraordinary clinical expertise and compassionate care provided by nurses. honors these special nurses from its staff who demonstrate exceptional patient care and act as role models for their peers. Brenda Acri, BSN, RN Tonya Alcorn, MSN, RN Barbara Arthur, RN Jessica Bartley, RN Abena-Yolanda Baskin, MSN, RN, CNOR Angela Durci, RN Denise Fontana, RN Lindsay Foster, RN Catherine Gathers-Robinson, RN, CNOR Megan Gold, BSN, BS, RN Janine Hair, BSN, RN Anna Kalafut, MSN, RN Gina Koch, MSN, RN, CMSRN Toni Kuhn, RN Karen Mains, RN Adel Mansour, RN Rosharon Price, RN Brittany Reaghard, BSN, RN Betty Scovern, BSN, RN Kimberly Soilis, RN, VA-BC Anna Mary Versace, BSN, RN DAISY Faculty Award Introduced in 2012, the DAISY Faculty Award honors registered nurse teachers for their commitment and inspirational influence on their students. Congratulations to this year s award recipient! Donna Jean Gardner, MSN, RN, CNE ACES Award The UPMC Award for Commitment and Excellence in Service (ACES) honors staff whose everyday actions and, in some instances, personal acts of courage and compassion, consistently provide leadership and superior service to colleagues, patients, and the community Awardees: Abena-Yolanda Baskin, MSN, RN, CNOR Jennifer Bordick, RN George Dillon, RN Cristina Gregg, RN Mary Hall (retired nurse) Rosharon Price, RN Adele Washington, BSN, RN Mary Ann Scully Excellence in Cardiovascular Nursing Award The Mary Ann Scully Excellence in Cardiovascular Nursing Award annually recognizes a registered nurse in the Pittsburgh region for his or her dedication and compassion to the field of cardiovascular nursing. Above & Beyond The Above & Beyond recognition program honors one UPMC St. Margaret staff member, physician, or volunteer each month for their extraordinary service to our patients. 2011/2012 Awardees George Dillon, RN Susan Evans, MSN, RN, CMSRN Erica Greenwald, RN Mary Hall (retired nurse) Toni Kuhn, RN Shelly Maloney, RN Susan Murray, MSN, RN Maureen Scuillo, RN Carol Slagel, RN Kariane Stuebgen, RN, CCRN Casey Witt-Patterson, RN Tracy Yussefabad, RN Honorable Mention: Kevin Boyle, RN Bonnie Brannagan, RN, ONC Donna Gardner, RN Janine Hair, BSN, RN Adele Washington, BSN, RN Michelle Whiteman, RN, ASN Donations were made to the St. Margaret Foundation, the hospital s fundraising arm, in honor of these nurses: Valerie Araque-Voelker, RDMS Maureen Cecil, BSN, RN John Clatty, BSN, RN Robert Michael Coppala, MSN, RN Donna Dzvonick, RN Elizabeth Eiszler, RN Tiffany Gustafson, BSN, RN Kurt Heinauer, RN Leslie Johnson, RN Margaret Runco, MSN, RN Leonard Slade, BSN, RN Jamey Shirley, NA Kim Wetzel, BSN, RN Jessica Wilson, RN Dignity and Respect Champion Award Built on a foundation of dignity and respect in the workplace and cultural competency in patient and family care, the mission of the Center for Inclusion at UPMC is to ensure that inclusion is at the core of what we do every day. The annual Dignity and Respect Champion Award recognizes staff members who are role models of dignity and respect. Tamara Welter, RN, 2011 award recipient LPN Recognition Award The LPN Recognition Award honors nursing care excellence by a licensed practical nurse. Joyce Holmes, LPN, 2011 award recipient MyHealth Role Model Each quarter, UPMC recognizes MyHealth Role Models who have succeeded in achieving and maintaining positive lifestyle changes, such as quitting smoking, achieving a weight loss goal, or motivating others to obtain healthier lifestyles. Adriana Jeffrey, RN Dawn Vocke, MSN, RN, CNOR Publications nurses share their knowledge through their publications. We acknowledge the following nurses who authored journal articles and book chapters in 2011 and Book Chapters Calderone, T.L. (2013). Information systems training. In T. Hebda & P.Czar (Eds.) Handbook of informatics for nurses and healthcare professionals (pp ). Boston, MA: Pearson Education, Inc. Keith Bailey, MSN, RN, CCRN 11 UPMC ST. MARGARET NURSING REPORT

13 Calderone, T.L. (2013). Telehealth. In T. Hebda & P. Czar (Eds). Handbook of informatics for nurses and healthcare professionals (pp ). Boston, MA: Pearson Education, Inc. Articles Donihi, A.C., Gibson, J.M., Noschese, M.L., DiNardo, M.M., Koerbel, G.L., Curll, M., & Korytkowski, M.T. (2011) Effect of a targeted glycemic management program on provider response to inpatient hyperglycemia. Endocrine Practice. 17(4), (Printed in 2011 UPMC Annual Report) Hebda, T., & Calderone, T. (2011). The TIGER initiative A model for the integration of informatics competencies. ihealth Connections, 1(1), (Printed in 2011 UPMC Annual Report) Hoolahan, S.E., Greenhouse, P.K., Hoffman, R.L. & Lehman, L.A. (2012). Energy capacity model for nurses. Journal of Nursing Administration, 43(2), Lewis, D.L., & Ciak, A.D. (2011). The impact of a simulation lab experience for nursing students. Nursing Education Perspectives, 32(4) Articles In Process Hebda, T. & Calderone, T. (2012). Informatics competencies for healthcare professionals: The TIGER Initiative Model. Drug Metabolism and Drug Interactions. (Accepted for publication) Degrees Earned Congratulations to our nurses who demonstrated their commitment to excellence in patient care by earning additional degrees. BSN Steven Foos Ohio University Heather Glasgow Ohio University Erica Greenwald Ohio University Maureen Lynch-Sciullo Ohio State University Katie Mazurek Edinboro University of PA David Santorella Waynesburg University Amanda Sheller University of Pittsburgh Charlene Walters Waynesburg University Shelly Wilson Clarion University of PA MSN Robert Coppala University of Alabama Betty Hepler Waynesburg University Jessica Stahl Walden University Mary Ulizio Indiana University of PA Professional Organizations We are proud of the leadership demonstrated by UPMC St. Margaret nurses as they held offices in professional organizations in 2011 and Ann Ciak Secretary Pennsylvania League for Nursing (PLN) Area Six Laura Kling Region IV Director (BOD) American Society of PeriAnesthesia Nurses (ASPAN) Denise Krall Secretary Three Rivers Chapter AACN Kimberly Lopes President Elect Emergency Nurse Association (ENA), Western Pennsylvania Chapter Mary Lou Taylor Trustee, Practice Chair, Governance Committee Pennsylvania Association of Nurse Anesthetists (PANA) Judith Tinelli Treasurer Association of Rehabilitation Nurses (ARN), Southwestern PA Chapter Professional Presentations Kudos to these nurses who shared their expertise with nursing colleagues by presenting to a variety of audiences in 2011 and Poster Presentations Heather Agnor Pictures are Worth a Thousand Words UPMC My Residency Program Mary C. Barkhymer Nurses Helping Nurses to Improve Patient Outcomes Redefining Excellence: Pennsylvania s 5 th Annual Best Health Care Practices Conference Summerdale, Pa. Patient Care Services Community Town Hall Meeting Implementation of Universal Protocol and the WHO Surgical Safety Checklist American Society for Quality (ASQ) 2011 Healthcare Conference Pittsburgh, Pa. Working Together to Prevent Wrong Site Surgery University of Pittsburgh Medical Center (UPMC) Pittsburgh, Pa. Theresa L. Calderone The Academic Electronic Health Record and Multiple Clinical Information Systems, Challenges to Simulation and Interoperability Integration in Nursing Curriculum ELITE Workshop, University of Pittsburgh School of Nursing Doris Cavlovich The Experience of Workplace Violence by Student Nurses Ann D. Ciak Enhancing the Nursing Student Experience at a Pediatric Hospital through Web-Based Learning UPMC Nurses Week, UPMC Shadyside Enhancing the Nursing Student Experience at a Pediatric Hospital through Web-Based Learning Clinical Research Forum, Enhancing the Nursing Student Experience at a Pediatric Hospital through Web-Based Learning Co-author: Kristen Straka, CHF SWPA Organization of Nurse Executives Nemacolin Woodlands Resort Bonnie V. Colaianne Multi-drug Resistant Organisms: New Challenges for Infection Prevention School of Nursing Alumni, UPMC Shadyside Diane Corr Restructuring Shared Governance: A Magnet Hospital s Journey to Nurse- Driven Evidence-Based Care Annual UPMC Nurses Week Conference I Believe I Can Fly: An Evidence- Based Model for a Nurse Residency Program at a Magnet Hospital Annual Research Conference Inspiring Youth Through Community Career Partnerships SWPONL Annual Conference (continued on page 13) Illuminating our Journey to Distinction 12

14 Janine Ringer Crider Surgical Wound Classification Update Research Day, Gina DeFalco Doris Cavlovich Ann Ciak Mary Dee Fisher Mary Beth Langdon Janey Roach Pre-licensure Students Perceived Importance of Concepts in Nursing Practice Susan DiNucci Multi-drug Resistant Organisms: New Challenges for Infection Prevention UPMC Trauma Nursing Symposium Pittsburgh, Pa. Surgical Safety Initiative: Use of Evidence on the Cutting Edge Traci Fick ED Throughput Highmark Quality BLUE Year-End UPMC Shadyside Veronica Findley Venous Thromboembolism Prophylaxis: Developing a Model of Care in the Long-Term Care Setting 6th Annual Research Forum, Venous Thromboembolism Prophylaxis: Developing a Model of Care in the Long-Term Care Setting UPMC Nurses Week, UPMC Shadyside Mary Dee Fisher Enhancing the Nursing Student Experience at a Pediatric Hospital Through Web-Based Learning Jolynn M. Gibson Diagnosis and Management of Diabetes University of Pittsburgh Diabetes and the Endocrine System Medical Surgical Review Course, UPMC Shadyside ABCs of Diabetes Care ADA Expo, David L. Lawrence Convention Center Pittsburgh, Pa. An Initiative to Improve Glycemic Control in a Community Hospital Co-presented with Andrea Pasierb, MSN, RN, CDE Family Medicine Residents, Diabetes Control: Reducing Length of Stay Medical Grand Rounds, Jolynn Gibson Andrea Pasierb Listening to the Staff Nurse: An Intervention to Meet Educational Needs Patricia Glod Interventions for Improved Bar Code Scanning Compliance SWPONL Conference Interventions for Improved Bar Code Scanning Compliance and Evaluating the Effectiveness of the Innovative Usage of a Nurse Call System UPMC Nurses Week Pittsburgh, Pa. Jessica Good Stroke Scale Review Stroke Conference, Jessica A. Graff Restructuring Shared Governance SWPONL Conference, Nemacolin Woodlands Resort Nursing Research Symposium, UPMC Nurse Week Conference, UPMC Shadyside Susan Gubash Role Changes to Improve Workflow Annual Research Forum Ruth Harris Back to the Bones Orthopedic Seminar, Pittsburgh Chapter of NAON Patricia L. Helms The Effects of Diabetes Worldwide Marjorie Jacobs National Association Health Care Quality Quality Education Conference Sacramento, Calif. Co-presenter: Rodney Rutkowski Utilization of Communication Tools to Reduce Preventable SNF Readmissions Roberta Jones Reducing Surgical Site Infections Harmar Outpatient Center Pittsburgh, Pa. Anna M. Kalafut ANA Bill of Rights Nursing Councils, ANA and Magnet Journal Club, Karen A. Kasely Patient Outcomes through Improved Nursing Assessment and Documentation of Peripheral Intravenous Catheters 2011 ANCC National Magnet Conference Baltimore, Md. Case Study: Crohns s Disease and Salmonella? Nursing Grand Rounds, Staffing/Throughput Resource Nurse Seminar, Improving IV Documentation: An Evidence-Based Journey Clinical Research Forum, Wendy M. Kastelic I Believe I Can Fly: An Evidence-Based Model for a Nurse Residency Program in a Magnet Hospital Annual Research Conference Workplace Violence and the Experience of the Student Nurse Research Day Workplace Violence and the Experience of the Student Nurse SWPONL, first place Nemacolin Woodlands Resort Evaluating the Effectiveness of the Innovative Usage of a Nurse Call System Nurse Research Forum, Kimberly Klamut Enhanced Patient Outcomes through Improved Nursing Assessment and Documentation of Peripheral Intervenous Catheters ANCC Magnet Conference Baltimore, Md. Kimberly Klamut Kathy Fowler Gina Koch And the Winner is You! Promoting Certification and Evidence Based Practice on a Medical-Surgical Unit Laura Kling Best Practices CDI - ASPAN Philadelphia, Pa. Strategic Planning: Gold Leaf CDI - ASPAN Philadelphia, Pa. Gina Koch Stroke Mimics Stroke Conference, Cheryl A. Lenhart Magnetize Your Nursing Outcomes Nursing Research Day, Clinical Research Forum, Shared Governance Kickoff, Nursing International Session, Relationship-Based Care Nursing Shared Governance Councils, 13 UPMC ST. MARGARET NURSING REPORT

15 Deborah Lewis Deborah Beer QSEN: Journey to Enhancing Student Nurse Quality and Safety Margaret Lisac Implementing a Geriatric Fracture Program Southwestern Pennsylvania Nursing Leaders Nemacolin Woodlands Resort Orthopedics in the OR UPMC Shadyside and Pittsburgh NAON Lecture, UPMC Shadyside Margaret Lisac Bonnie Anton Implementing a Geriatric Fracture Program: Lessons Learned from a Community Hospital Kristi Lonzo ENT Navigation Inservice, The Effect of Silver Dressings on Closed Surgical Incisions Susan Ober The Personal Touch: Nurses Making Post-op Phone Calls Reducing the Use of the Flash Cycle Andrea Pasierb Diabetes Control: Reducing LOS Medical Grand Rounds, An Initiative to Improve Glycemic Control in a Community Hospital Resident Seminar, Euphemia Powell Acute Pain in the Patient with Maintenance Therapy Journal Club, Catherine Recznik Disaster Response for Elementary and High School Education Majors Franciscan University Licensure for BSN Students Franciscan University Janey Roach Gina Defalco Mary Beth Langdon CPR Retention: Keeping to the Beat Bobbi Jo Skurko Stroke Conference, Isabel MacKinney-Smith Reducing Preventable 30 Day Hospital Readmissions Marcy Zera Sunday Hypothermia in the Surgical Patient Judith Tinelli Rehab Nursing: Advancing the FIM Purpose An Interdisciplinary Approach to an Efficient Therapy Schedule Linda Jean Wallace Impact and Importance of Stroke Protocol Order Sets Journal Club, Stroke Protocol Stroke Seminar, Susan Wharrey Susan Gubash Katherine Kline Role Changes to Improve Workflow Lawrenceville Family Health Center Grace Michele Winter Restructuring of Shared Governance and UPMC Professional Practice Council Nurses Week, UPMC Shadyside Clinical Research Forum, Southwestern Pennsylvania Organization of Nurse Leaders, Nemacolin Woodlands Resort Karen Lynn Zanin Universal Protocol Highmark Superbowl Presentation Universal Protocol American Society for Quality Oakland, Pa. Podium Presentations Tonya Alcorn Stroke Risk Factors Stroke Conference, Theresa L. Calderone Nursing Super Users: Then and Now 30th Annual Rutgers International Computers in Nursing Conference Veronica Findley VTE: A Patient Safety Initiative (Bariatric Series) Marjorie Jacobs Beyond the Bedside: Reducing 30-Day Readmissions Duquesne University Club, Patient Safety Fellowship Pittsburgh, Pa. Beyond the Bedside: Reducing 30-Day Readmissions Patient Quality and Safety Conference, HAP Symposium Harrisburg, Pa. VTE Prevention Highmark Best Practice Forum Pittsburgh, Pa. Panel discussions Judith Tinelli Nursing Innovation: Beyond the Horizon Speaker, Panel discussion University of Pittsburgh Horizons Clinical Nurse Leader Conference Certifications Accredited Case Manager (ACM) Roxanne Balog Maryellen Cunliff Judy DeSantis Margaret Dolhi Cristina Gregg Marjorie Jacobs Aimee Wilson Linda Jean Wallace Certified Ambulatory Peri-Anesthesia Nurse (CAPA) Laura Kling Esther Haduch-Whitlinger Jane Rea Elizabeth Scott Certified Care Manager (CCM) Isabel MacKinney-Smith Certified Diabetes Educator (CDE) Jolynn Gibson Catherine Novak Andrea Pasierb Certified Emergency Nurse (CEN) Lori Kelly Denise Krall Tina Mourra Meaghan Schaffhauser Shari Spangler Certified Gastroenterology Registered Nurse (CGRN) Tina Galli Aleta Himes Certified Hospice and Palliative Nurse (CHPN) Darcy Green Certified Infection Control (CIC) Bonnie Colaianne Susan DiNucci Certified Medical-Surgical Registered Nurse (CMSRN) Kelsey Archibald Dawn Baker Jeanny Catapia Rita Cook Susan Ann Fenoglietto Mary Ferguson Kathleen Fowler (continued on page 15) Illuminating our Journey to Distinction 14

16 Connie Goheen Jessica Graff Erica Greenwald Patricia Hanselman Aleta Himes Pamela Jaecke Noelle Kakuk Karen Kasely Lynne Kijowski Mary Jo Klebine Gina Koch Mary Kochick Marie Langdon Suzanne Lutz Karen Mains Ronald Mennow Susan McKinney Roberta Olszewski Jacqueline Morgan Kristin Jean Swierczewski Christine Sulkowski Dawn Scrima Leeba Sanu Aimee Wilson Vittoria Zenone Certified Nurse Educator (CNE) Deborah Beer Mary Ellen Gallagher Donna Gardner Deborah Lewis Certified Nurse Manager Leader (CNML) Tanya Hoebel Certified Nurse Operating Room (CNOR) Robyn Arner Mary Barkhymer Abena-Yolanda Baskin Julie Ann Farren Denise Filiaggi Catherine Gathers-Robinson Robin Hemphill Roberta Jones Denise Koch Kristi Lonzo Charlene Lynch Susan Ober Brittany Pore Rosharon Price Janine Ringer-Crider Deborah Ryan Heather Santillo Elaine Sikon Marcy Sunday Dawn Vocke Virginia Wright Karen Lynn Zanin Certified Ostomy Care Nurse (COCN) Miriam Cohen-Melamed Certified Pediatric Nurse (CPN) Mary Dee Fisher Susanna Marietta-Prior Certified Post Anesthesia Nurse (CPNA) Rosalyn Denillo Nicole Jones Laura Kling Certified Professional in Healthcare Quality (CPHQ) Marjorie Jacobs Certified Radiology Nurse (CRN) Kathleen McKeag Certified Registered Nurse Anesthetist (CRNA) Lisa Adams-Vacheresse Robert Andra Jay Belschner Lisa Berdar Ruth Bisko Heather Butler Kelly Cannon Mary Elaine Castillenti Hayley Chemski Linda Crippen Kelley Diamond Cynthia Donatelli Barb Dunn Amy Graham April Hassler Pauline Dishler Mary Humphrey Donna Jordanhazy Nicole Karpinski Cindy Ketchmark-Green Nicole Lorah Amy McConaghy Melissa McConnell Andy Miller Kathleen Miller Julie Montgomery Debbie Pigozzi Scott Radinovic Imy Rosenblatt Ralph Ruggiero Holly Salley Randa Shannon Nick Shinsky Jerold Shratte Mary Lou Taylor Sue Trachine Marge Tuite Mary D. Ulizio Certified Registered Nurse Practitioner (CRNP) Linda Devine (Adult) Michelle Casey (Family) Kimberly Conley (Family) Heather Grubich (Family) Ron Mennow (Family) Karen Nelson (Family) Cheryl Pivirotto (Family) Donna Rothman (Adult) Karen Weimer (Family) Certified Rehabilitation Registered Nurse (CRRN) Kim Hitrik Stacie Shevchik Judith Tinelli Certified Wound Care Nurse (CWCN) Shannon Moretti Clinical Nurse Leader (CNL) Bonnie Colaianne Judith Tinelli Critical Care Registered Nurse (CCRN) Keith Bailey Holly Castello Doris Cavlovich Hayley Chemski Valerie DiSanti Barbara Green-Miller Kara Griffith Kim Klamut Denise Krall Trudy Praniewicz Rhoda Shoaf Rebecca Sproul Kariane Steubgen Kimberly Yurchick Oncology Certified Nurse (OCN) Regina Easler Roberta Olszewski Orthopedic Nurse Certified (ONC) Bonnie Brannagan Donna Dzvonick Ruth Harris Denise Letzelter Margaret Lisac Danette Mandella Janey Roach Margaret Runco Judith Tinelli Progressive Care Certified Nurse (PCCN) Rita Cook Caroline Laurito Registered Nurse-Board Certified (RN-BC) Theresa Calderone Cheryl Lenhart Euphemia Powell Sexual Assault Nurse Examiner (SANE) Debra Shane Vascular Access- Board Certified (VA-BC) Kimberly Soilis Grace Michelle Winter Sincere appreciation is extended to the following nurses for their contributions to the 2011/2012 Nursing Annual Report: Mary Barkhymer, MSN, MHA, RN, CNOR Bonnie Colaianne, MSN, CNL, RN, CIC Traci Fick, MSN, RN (contributor and editor) Marjorie Jacobs, MSN, RN, ACM, CPHQ Lisa Lehman, MSN, RN Cheryl Lenhart, BSN, HRM, RN-BC Kristi Lonzo, BSN, RN, CNOR Bobbie Jo Skurko, BSN, RN Colleen Sunday, MSN, RN