Improving Perinatal Quality Outcomes: Assessing the Efficacy of an Asynchronous Learning Activity

Transcription

1 Improving Perinatal Quality Outcomes: Assessing the Efficacy of an Asynchronous Learning Activity Nursing Research Conference May 7, 2014 Amy Scott, MSN, WHNP, RNC-OB Janet Trial, EdD, CNM

2 OBJECTIVES At the close of the learning session, learners will be able to: 1. Describe the ideal context for learners to participate in asynchronous learning. 2. Explain four components of an asynchronous educational intervention. 3. Provide an example of an asynchronous learning experience for individual clinical specialty. **Presenters report no conflict of interest.

3 BACKGROUND Hypertension (HTN) is one of the most common medical disorders of pregnancy Accurate blood pressure (BP) measurement in the OB patient is essential Accuracy is elusive Correct patient position and cuff size are key Clinicians may manipulate measurement to obtain lowest BP 1. Pickering, T., Hall, J., Appel, L., Falkner, B., Graves, J., Hill, M., Jones, D., Kurtz, T., Sheps, S. & Roccella, E. (2005).

4 BACKGROUND Annual Competency Validation 2013 BP Measurement Station for OB Nurses Equipment, patient position, arm circumference & cuff size demonstration / discussion Review of Women s Best Practice Team Acute HTN in Pregnancy Guidelines / Order Set Introduction to CMQCC Preeclampsia Collaborative

5 Preeclampsia Toolkit Draft v joined the CMQCC Preeclampsia Collaborative #1 Monthly interprofessional meetings convened early 2013 Goal: Improve care and outcomes for the preeclampsia patient prenatally, intrapartum and postpartum

6 CMQCC Preeclampsia Collaborative Is Group Think for improving maternal quality care Involves interprofessional participants throughout the state To meet goal of improved care, focus is: Accurate BP measurement Initiating anti-htn meds early / aggressively : Transforming Maternity Care

7 BACKGROUND CMQCC ACUTE HTN BP MEASUREMENT GUIDE Automated BP machine underestimates both systolic and diastolic readings by as much as 10 mm Hg. If initial BP Measurement taken with automated BP machine is 160 OR 105 YOU NEED TO: Take 2 nd BP using manual cuff method (sphygmomanometer and stethoscope) 15 minutes from the initial BP measurement. If BP is 160 OR 105, goal is to treat with IV anti-htn med within 30 minutes of this 2 nd BP obtained via manual cuff method. Initiate Acute HTN order set. Arm Circumference (cm) Cuff Size Small Adult Adult Long Large Adult Adult Thigh **For upper-arm measurements greater than 50cm, the American Heart Association suggests using a cuff on the forearm and feeling for the appearance of the radial pulse at the wrist to estimate systolic blood pressure. However, the accuracy of forearm measurement is not reliable. HOW TO TAKE AN ACCURATE BLOOD PRESSURE Measure patient s arm circumference (cm) and obtain correct size cuff based on measurement (SEE TABLE). Check cuff for any defects. Patient to sit quietly for 5 minutes before BP measured. Bare upper arm of any restrictive clothing. Use a low or semi-fowlers position with slight left or right tilt to provide uterine displacement, support patient s arm at heart level. Patient s feet should be flat on floor or legs flat on bed/gurney, not dangling from examination table or bed, and her legs uncrossed. Instruct the patient not to talk while BP is being obtained. For auscultatory measurement: use first audible sound (Kortokoff I) as systolic pressure and use disappearance of sound (Kortokoff V) as diastolic pressure. Read to the nearest 2 mmhg, use highest reading. Do not reposition patient to either side to obtain a lower BP as this will give you a false reading. If BP must be measured with patient in side-lying position, take with cuff on lower arm more closely approximates actual BP. There is a mm Hg underestimation difference between upper & lower arm when BP measured in side-lying position. Document BP: auto or manual cuff, cuff size, patient position, and arm in which taken. Place patient label on cuff: Cuff stays with patient. Tools were created to guide care Provided education on CMQCC Preeclampsia Guidelines Topic: Maternity service teams review and document sequence of events, successes with and barriers to swift and coordinated response to preeclampsia. Goal: De-brief 100% of cases of new onset severe hypertension with preeclampsia or eclampsia ( 160 OR >105) or chronic/gestational hypertension with superimposed preeclampsia (see inclusion table) (Include patients from L&D, PP, ED) (Process Measure, P3) Minimum Participants: Primary RN and MD participate in the de-briefing session; ideally any and all providers participate. Instructions: Complete immediately after event. Patient Location (Check all that apply) OB Triage L&D PSCU Postpartum ED Debrief Participants: Primary MD: YES NO Primary RN: YES NO Coordinator: YES NO AUM/RC: YES NO Resident: YES NO Anesthesia: YES NO Medical Management Highest B/P prior to treatment: Time BP reached 160 or >105: (hh:mm) (after validation) Time of first treatment: (hh:mm) Medical Management: What went well? (Check all that apply) Communication went well Decision-making went well Teamwork went well Assessing the situation went well Leadership went well Other Briefly describe: Opportunities for improvement: human factors (Check all that apply) Communication needed improvement Assessing needed improvement Teamwork needed improvement Delay in recognition Leadership needed improvement Other Decision-making needed improvement Briefly describe: ORDER SET INITIATED (Acute Hypertension in Pregnancy IP) Medications (Check all given) Labetalol IV PO Hydralyzine IV PO Nifedipine Other (Drug, dose, route) Monitor Medical Management Lowest B/P for first hour after completing TX: Was there a SUDDEN change in the FHR that required intervention? YES NO If YES, did the intervention require emergent delivery? YES NO Patient is Antepartum Postpartum Magnesium Sulfate Loading Dose: 4gm 6gm Other Maintenance Dose: 1gm/hr 2gm/hr 3gm/hr Other Opportunities for improvement: non-human factors (Check all that apply) Delay in HTN medications Inadequate support (in-unit/other areas) Other Medications issues Equipment issues Delays in transport (intra-, inter-hospital transport) Other Briefly describe: Label:

8 BACKGROUND Created Preeclampsia/ Acute HTN kits Nurses to implement use of kit if first BP is 160 Systolic BP or 105 Diastolic BP

9 PROBLEM One CMQCC Collaborative Process Measure Deliverable: 80% of Clinical Staff trained & score >80% on accurate BP measurement methods Unable to prove learning occurred as a result of Annual Competency Validation CMQCC Preeclampsia Education Asynchronous Learning to the rescue

10 INTRODUCTION Participants: 207 RN s (83% of staff) Setting: Labor & Delivery and Mother Baby Unit at Tertiary Perinatal Care Hospital When: Fall 2013

11 METHODS - Learning Theories 1. Adult Education - active learning, goals, feedback 1 2. Cognitive Learning motivation, familiar frame, self-evaluation 2 3. Constructionist - learning structures, active participation, feedback 3 1. Bleakley, A. (2006). 2. Abraham, S. C., M.; Taylor, A.; McBride, A.; Boyd, C.. (2003). 3. Bleakley, A. (2006)..

12 INTRODUCTION - GOAL Competence minimum level of performance for independent practice

13 METHODS Asynchronous Learning: A student-centered teaching method that uses electronic learning resources to facilitate information sharing outside the constraints of time and place among a network of people.

14 Methods - Evaluation Theory Formative: to improve Summative: to recognize & reward Informal (but intentional) Ongoing Detailed Individual Private Formal Specific points in time General Comparative Public

15 METHODS Learning Activity 1. Content Review 24 slides 2. Leaner Evaluation - 11 slides 3. Self Assessment Quiz Survey Monkey

16 METHODS Content Review

17 METHODS - Evaluation

18 RESULTS Activity outcomes

19 RESULTS Activity outcomes 3. On your reassessment A.G. s blood pressure measures 170/108. Please drag and drop the following choices in the order you would preform, with your first action choice in the top position:

20 Acute Hypertensive Crisis Learning Evaluation - KEY 3. On your reassessment A.G. s blood pressure measures 170/108. Please list the steps you would take in the proper order: 1. Notify the patients physician (house staff) 2. Initiate Acute Hypertension in Pregnancy order set 3. Apply pulse oximeter. 4. Give antihypertensive medication 5. Notify your unit coordinator AND... Many of you are SO correct, there is no way to account for your fabulous abilities to multi task on a learning activity like this!

21 RESULTS EMB Feedback

22 RESULTS EMB Feedback

23 RESULTS Unexpected Outcomes Professional Dialogs Teachable Moments Celebrity Patients

24 Appropriate Treatment in 30 Minutes What departments have you already included in the project, and which, if any, would you like to include? : Transforming Maternity Care

25 : Transforming Maternity Care

26 CONCLUSIONS Asynchronous Learning Effective teaching tool. Creates an ongoing dialog. Has potential to create sustained change. Cost effective.

27 THANKYOU We d be happy to answer any questions? ascott@memorialcare.org jtrial@memorialcare.org