news views MAGNET MAGNET Lisa Rowen s Rounds: 2014 Annual Magnet Conference

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1 news views Fall 2014 University of Maryland Medical Center A Publication of the Department of Nursing and Patient Care Services Lisa Rowen s Rounds: 2014 Annual Magnet Conference The annual Magnet conference never fails to offer a whole range of stimulating and informative experiences: excellent plenary sessions with speakers who prompt you to stretch your way of thinking, focused sessions on research and quality improvement studies with supporting evidence about best practices on a variety of topics, and opportunities to connect with nursing colleagues and our profession. The 2014 conference was no exception and in addition, we celebrated our re-designation with great joy. Dallas provided the backdrop and we were given a hearty Texas welcome and treated to some iconic sights. As you read the following descriptions that your Medical Center nurse colleagues have shared, you will note some common themes and insight: We were all struck by the fact that UMMC Nursing is already doing much of what was shared at the conference, We treasured the time together, getting to know each other better while learning together, The notion of a Reverse Mentor was one that captivated many of us, It s important to take time to feed your soul with opportunities to explore and learn new ideas and ways of practicing, and We felt a sense of pride as UMMC nurses. Lisa Rowen, DNSc, RN, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer The most meaningful thing I learned at the conference was to lead from the inside-out. This concept resonated with me because it makes so much sense. Each of us, as formal and informal leaders, should wear our values inside-out, so that others can clearly understand our priorities through our words, actions, and deeds. The term inside-out speaks to our inner core, our heart. Inside is both our most vulnerable spot, because it means the most to us, as well as the strongest part of each of us because it is our guiding light, our north star. Living and leading from the inside-out is true, transparent, and honest. It offers others insight and clarity about us and guides us to live in a way that supports our personal why, which is our inner mission and the reason why we are in health care. MAGNET REFLECTIONS MAGNET Read on for a sample of other reflections about the 2014 Annual Magnet Conference that your colleagues have shared. You can read the full comments by each of these colleagues on our nursing page, accessed through the UMMC Insider. Rachel Maranzano, BSN, RN, CCRN, SCN I, Surgical Intensive Care Unit Preparing for the conference was overwhelming at first; coordinating family schedules, work, travel, and choosing which presentations to attend. For each of the nine time blocks, over three days, there were 15 different presentations to choose from. However, I could easily identify topics that piqued my interests when reviewing the session abstracts on the conference software applications (apps). Attending the general sessions with 7,000 nurses in one room was electrifying. I was inspired by Jennifer Arnold, MD, MSc, FAAP, of The Learning Channel s (TLC) show The Little Couple and intrigued by Jean Watson, PhD, FMN, RN, nurse theorist. I felt proud and supported to be representing UMMC and all that we have accomplished. continued on page 4.

2 2 Fall In This Issue Lisa Rowen s Rounds 2014 Magnet Conference Corporate Compliance Electronic Medical Records A Nurse s Perspective Lung Rescue Unit Using Inter-Professional Simulation-Based Education Registered Dietitians Obtain Order-Writing Privileges Cardiac Electrophysiology Lab Expanding Role of Respiratory Care in ICUs Certification Corner New Process for Product In-Services Achievements Clinical Education Council When Change Impacts Delivery of Patient Care UMMC Employee in the News Investigational Drug Services at UMMC Core Measures Blood Glucose Monitoring in Surgical Patients with BMI > 30 kg/m 2 Journal Club Clinical Practice Update Corporate Compliance Christine Bachrach, UMMS Vice President & Chief Compliance Officer, and Toya Jackson, Director of Compliance, CHC In each issue, the Medical Center Compliance Program provides a short Frequently Asked Question (FAQ) for News & Views. We are looking for new ways to reach out to employees to raise awareness of compliance issues. Please let us know what you think, or suggest topics by ing compliance@umm.edu or tjackson4@umm.edu. Compliance FAQ Q: A vendor who is assisting various units with education about new drugs and devices frequently brings in lunch for the staff. Is this allowable? A: The Corporate Compliance Relationship policy does allow vendors to bring in meals. However, in the situation described, it is stated that the vendor frequently brings in meals, and under these circumstances it wouldn t be allowed. The policy states that vendors and referral sources are allowed to bring in meals for consumption as long as they are infrequent and available to all staff. Find news&views online at and on the UMMC INSIDER at Editor-in-Chief Kimmith Jones, DNP, RN, CCNS, RN-BC Director of Translation to Nursing Practice Clinical Practice and Professional Development Managing Editor Susan Carey, MS Lead, Operations Clinical Practice and Professional Development Associate Editor Mike Costello, MHA Project Specialist Clinical Practice and Professional Development Editorial Board Lisa Rowen, DNSc, RN, FAAN Senior Vice President of Patient Care Services and Chief Nursing Officer Suzanne Leiter Executive Assistant to the Senior Vice President of Patient Care Services and Chief Nursing Officer Greg Raymond, MS, MBA, RN Director, Nursing and Patient Care Services Clinical Practice and Professional Development, Neuroscience, Behavioral Health and Supplemental Staffing Chris Lindsley Director, Communication Services University of Maryland Medical System Anne Haddad Publications Editor University of Maryland Medical System NEWS & VIEWS is published quarterly by the Department of Nursing and Patient Care Services of the University of Maryland Medical Center. Scope of Publication The scope of NEWS & VIEWS is to provide clinical and professional nursing and patient care services practice topics that focus on inpatient, procedural, and ambulatory areas. Submission Guidelines Send completed articles via to mcostello@umm.edu. Please follow the guidelines provided below. 1. Font Times New Roman 12 pt. black only. 2. Length Maximum three double spaced typed pages. 3. Include name, position title, credentials, and practice area for all writers and anyone named in the article. 4. Authors must proofread the article for spelling, grammar, and punctuation before submitting. 5. Provide photos and embedded images in separate.jpg files. 6. Submit trend data in graphic format with labeled axes. 7. References must be numbered consecutively and provided at the end of the article. 8. Editor will seek expert review of articles to verify and validate content. 9. Articles will be accepted based on appropriateness of content and availability of space in each issue. 10. Articles that do not meet the above guidelines will be returned to the author(s) for revision and resubmission. ISSUE Winter 2015 Spring 2015 Summer 2015 Fall 2015 DUE DATE January 5, 2015 April 27, 2015 July 6, 2015 October 5, 2015 Displaying Credentials The UMMC Standard for displaying of credentials is based on the ANCC Guidelines. The preferred order is: highest earned degree (can list more than one if in different fields) licensure state designations or requirements national certifications and honors other recognitions Nurses with two or more nursing degrees (MSN, BSN) should only list their highest nursing degree, along with other degrees obtained. Example: Betty Smith, MSN, MBA, RN. Why this order: The education degree comes first because it is a permanent credential, meaning it cannot be taken away except under extreme circumstances. The next two credentials (licensure and state designations/requirements) are required for you to practice. National certification is sometimes voluntary. Awards, honors, and other recognitions are always voluntary. If you would like additional information, please visit and search using the word credentials.

3 news &views 3 AMBULATORY SERVICES Journey to the Electronic Medical Record: A Nurse s Perspective Annie Grace, BSN, RN According to HealthIT.gov, implementation of an electronic health record (EHR) contributes to: w Improved quality and convenience of patient care w Increased patient participation in their care w Improved accuracy of diagnoses and health outcomes w Improved care coordination w Increased practice efficiencies and cost savings It is an amazing experience as a nurse, working for one of the best hospitals in the United States, to be able to take care of complex patients who are seen by multiple sub-specialty medical teams. However, one of the problems that I have commonly encountered is the inability to look up and read all of the notes from the different doctors that my patients see on a regular basis. Because of this, I had to rely on what my patients or their family members told me. Recently, though, I transitioned from an inpatient unit at UMMC to the ambulatory services division and was introduced to a new way to document the care of my patients. In this outpatient setting, the electronic health record (EPIC) had replaced the traditional paper chart. When I now see patients, I am able to easily read all of the different notes from all of the different doctors that my complex patients are visiting. Because of this, I am able to give my patients the best care possible. The ambulatory clinics implemented EPIC about two years ago. According to EPIC s website (2014), Information is shared securely in two ways: Care Everywhere, where the doctor controls the flow of data across organizations, and MyPortfolio, where patients can engage in their own health information. When a patient comes to a facility that uses EPIC, they are able to create a MyPortfolio account where they can help manage their health care. The patient is able to see all of their appointments, doctors, and see some of their blood test results. Medical providers are able to read each other s notes, see any imaging scans, and review blood work results before going in to see a patient. This approach allows for a complete loop of communication between all of the different sub-specialties, helping to deliver the best care possible and to improve patient outcomes. Currently, the inpatient units use Cerner, which is considerably different than EPIC. In my previous role as a pediatric intensive care unit (PICU) nurse, I was only able to see the notes, images, and labs from when the patient was in the hospital. I had to rely on what the parents told me about their child, which can contribute to misunderstandings. When all of the inpatient units at UMMC transition to EPIC, I will be able to see all of the medications that the patient is on at home, all of the past notes, imaging, labs, and surgeries, as well 100% 95% 90% 85% 80% 75% 70% Figure 1 % of pts who had BP measured at each visit as the appointments the patient has scheduled. According to Teefra Brown, RN, CN II, EPIC has improved safe patient care because once you chart something in EPIC, it populates extremely quickly. In Cerner there is a lag time for some of the documentation. Since the implementation of EPIC, Jardiolyn Patterson, RN, manager of the neurology ambulatory clinic, noticed many improvements in their workflow. According to her, when the paper record was still being used, there was always a delay in accessing the chart. Since EPIC, a provider can immediately access the record from anywhere and communication among the team is enhanced by use of the inbox messaging feature. Moreover, coordination of care between providers, as well as across the continuum of care, is enhanced, along with engagement and communication between the patient and clinical staff. This is especially the case as it relates to clinical queries, medication refills, and appointment management. Patients are able to view parts of their records in a secure way, which eliminates wait time on the phone and the proverbial playing of phone tag. As a result of the EPIC implementation, and as part of the ongoing medical record Compliance with Record Audits Pt asked about learning preferences Pt asked about barriers to learning Pt education provided auditing process, ambulatory services made considerable improvement over a two-year period on their compliance with documenting four key points of patient care (Figure 1). Moving to an electronic health record requires planning, training, and coordination with the staff to maximize all of the benefits. As a nurse who has transitioned from the paper record to the electronic record, I have witnessed first-hand the improvement in care and the increased satisfaction among our patients. A special thanks to Jacqueline Rodriguez, BSN, RN, for her contributions to this article. FY12 FY14

4 4 Fall 2014 Lisa Rowen s Rounds, continued from page 1. Jennifer Motley, BSN, RN, PCCN-CMC SCN II, Shock Trauma Center Christine L. Byerly, BSN, RNC-NIC SCN II, Neonatal ICU, Magnet Champion The conference offers inspirational forward thinkers like Jack Uldrich, renowned global futurist, who challenges us to unlearn old ways of thinking and promote change; and Jean Watson, PhD, FMN, RN, who reminds us of the humanness of nursing, healing, and health. I attended a session that inspired me to want to further explore a nursing research idea. After 25 years of nursing, I am still excited at the prospect of all that we can achieve. The theme of the conference was innovate, involve, inspire, and the conference did just that. Session after session, we heard about amazing nurses making changes to the well-established methods in their hospitals. From the adaption of a new online precepting tool at a hospital in New York that helps develop an above-average selection of preceptors who are paid $10 more an hour, to a trauma hospital in Oregon starting falls-prevention interdisciplinary rounds to decrease falls on an acute care unit, you are inspired to learn something to take back to your unit and your hospital. The best part of the Magnet conference was getting to know all of the forty-plus members of the Medical Center that were so honored to be asked to attend the conference. We were from psychiatry, cardiac surgery, trauma, SICU, neuro, emergency department, and more. Some of us knew each other, but most did not. Relationships were formed, especially with our newfound friend, our roommate. Having this time away from our regular schedule helped to recharge, form new alliances, and collaborate with one another for our ultimate outcome excellent patient care. Stacy Foertsch, BSN, RN CN II, Cardiac Surgery David G. Hunt, MSN, MBA, RN Vice President, Patient Access, Patient Flow & Emergency Services The conference is an international event that pulls together exceptional nurses from across the globe to promote best practice and learning. It celebrates the unique profession that is nursing. I learned something new in every session that I had the opportunity to attend. One particular standout experience was a lecture by Jack Uldrich, a renowned global futurist, independent scholar, sought-after business speaker, and best-selling author. Uldrich described the rapidly-changing pace of technology and its impact on health care. He suggests that the tremendous growth in data storage, processing, bandwidth, scanning, and robotics will exponentially change how we care for people. Examples of some of these major changes in technology included the impact of 3-D printers, which can map out identical replicas of internal human organs prior to surgical procedures, coupled with advanced robotics therapies. In Dallas, I learned how to Perfect the Art of Precepting and enjoyed Growing Our Own: Developing and Mentoring the Next Generation of Nurse Leaders. I met amazing nurses doing great things from across the country. I came home with many new colleagues and friends from right here in this institution. Although we met in Dallas, we returned home as one, here at UMMC. Patrick Brown, MS, RN CN II, Psychiatric Emergency Services One of the speakers, Jack Uldrich, focused on exponential growth as a constant variable in the information age. However, the health care industry still takes 15 to 18 years to implement best evidence into clinical practice. If we can recognize and address the barriers to implementing evidence into practice, and expedite the process, we can hope to keep up with exponential change and paradigm shifts in the culture of health care. Karen Lyons, BSN, RN, CCHP Nurse Manager, University Health Center (UHC), University of Maryland Medical Center One presentation was focused on patient-centered care in an ambulatory environment. One slide in particular caught my attention as succinctly summarizing the way the patient experience was and where it needs to go to be successful in the new ambulatory health care environment. I plan to share that with the UHC team to help us in our goals related to patient experience. Lindsey Gray, BSN, RN CN II, Psychiatry Going to the Magnet conference in Dallas, Texas, really was a turning point in my nursing career. After attending the conference, I was filled with ideas, filled with empowerment, filled with excitement and, most importantly, I was filled with motivation to really make changes on my unit. It was just the type of thing I needed to remember why I became a nurse and it truly has inspired me to be an even better nurse. In fact, on my flight home, my peers laughed as I made a long list of goals for the year for my unit. continued on page 5.

5 news &views 5 Lisa Rowen s Rounds, continued from page 4. Nancy Corbitt, BSN, RN, OCN, CRNI SCN II, Oncology The session that really intrigued me pertained to sepsis; more importantly, nurse-driven screening. This session discussed how a hospital decreased sepsis mortality by using a sepsis screening tool and a nurse-driven lactate blood drawing procedure. I left the session saying to myself that We can do this and make a difference. Cara Sullivan, BSN, RN CN II, Women s and Children s Health In an organization as big as UMMC, it is easy to feel like a small fish in a big pond. This conference has changed that perception for me. Attending the Magnet conference gave me a chance to meet many other people throughout this organization that I would otherwise not have had a chance to meet. Maggie Ryan, BSN, RN CN II, Ambulatory Surgery Care Unit The conference offered a wealth of information regarding nursing best practice, cultivating leadership and improving patient outcomes. Most importantly, the conference highlighted the essential work that bedside nurses do. It was a very empowering experience! Lucy Miner, BSN, RN, PCCN SCN II, Surgery and Cardiac Care I felt proud to work for an organization that has come so far. At the same time, I realized that we still have a lot of work to do! As we move forward into a different electronic medical record system (EPIC) and face challenges related to the changing health care environment, embracing change and unlearning some of what we have done in the past will be crucial. The Magnet conference helped to give me a fresh perspective and insight for how to Think Big as our organization moves forward. Cindy Dove, MS, RN Nurse Manager, Surgical ICU, Surgical IMC, and Surgical Progressive Care My staff members who attended are so engaged and excited to share what they learned. Magnet is by far my favorite conference. I felt pride watching our leaders present The Impact of Leadership Development on Patient and Nursing Outcomes at the conference. Nurses at one Magnet hospital committed to sitting with their patients for five minutes every shift at eye level, doing nothing other than having a conversation, making eye contact or just holding a hand. Patricia Woltz, PhD, RN Director of Nursing Research Tia Milburn, BA Project Specialist, Magnet Champion Group Facilitator The session Using emr Technology to Steer Intraprofessional Teams to Real Time Quality Metrics featured the Hershey Medical Center, whose quality metric dashboard was built to be accessible to all clinicians via their emr. The presenters talked about adoption of the dashboard in their facility, which required role modeling to integrate its use into daily rounds and patient hand-offs. Improvements at Hershey attributed to implementing the dashboard were impressive and sustained, particularly for documentation completeness, vaccines, HAPU, CLABSI, CAUTI, and VAP. As UMMC moves to embrace EPIC and Meaningful Use, this Magnet story provides us with a vision on how it may be used for improving health care delivery. I was motivated to encourage our Magnet Champions and leadership team to begin mapping out our best evidence and stories. There were noteworthy tips provided for project planning, resource management, and staff engagement. Overall, I was grateful to be included and had a magnificent time at the Magnet conference. I recognize that we are still a cut above others in our industry and I am proud to be a part the UMMC nursing team. Meredith Huffines, BA, MS, RN SCN II, Surgical ICU I attended a concurrent session during the Magnet conference that focused on an evidence-based approach to improving sleep for patients and families. I plan to share the interventions with our critical care operations subgroup, Rise and Shine committee, which focuses on delirium prevention and treatment. I am hoping we can implement similar strategies here at UMMC to help facilitate noise reduction and provide peace, quiet, and comfort for our patients and families. It was very exciting to be recognized in such a large forum as one of the elite hospital organizations in the world that has been validated in demonstrating nursing excellence. continued on page 26.

6 6 Fall 2014 R Adams Cowley Shock Trauma Center Opens Lung Rescue Unit Using Inter-Professional Simulation-Based Education Jason Bates, MA; Mark Bauman, MS, RN, CCRN; and Vanzetta James, MS, RN, CCRN Leadership Uses Simulation to Meet Inter-Professional Challenges On August 5, 2014, the R Adams Cowley Shock Trauma Center (STC) opened the doors to a brand new Lung Rescue Unit (LRU). Located on the sixth floor of STC, the LRU is a four-bed unit focusing on the treatment of patients with acute pulmonary dysfunction utilizing treatment options, including prone positional therapy and extracorporeal membrane oxygenation (ECMO). Under the leadership of medical director Jay Menaker MD; surgical director Si Pham, MD; and nurse manager Vanzetta James, MS, RN, CCRN, the unit is staffed with attending physicians, nurse practitioners, physician assistants, nurses, patient care technicians, unit secretaries, perfusionists, respiratory therapists, and individuals from rehabilitation services. The LRU provides specialized care for some of the most critically ill patients in the region. A three day in-situ inter-professional simulation event was conducted to prepare the new LRU team for patient care in the unit. The LRU education and training team, consisting of Vanzetta James; senior clinical nurse Mark Bauman, MS, RN, CCRN; nurse practitioner Adam Rabinowitz, CRNP; clinical nurse specialist Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN; and, lead perfusionist Raymond Rector, CCP, faced the major challenge of bringing together a diverse group of health care providers with varying experiences and skill sets, educating them on care of the ECMO patient and preparing them to function as a team. Confronted with creating and implementing training objectives to facilitate opening the unit, the team developed simulated events focusing on inter-professional skills, communication, and team building to help the group operate as a highly functioning team. A week-long educational session with emphasis on theory and best practice had already been held the previous month. The challenge now lay in integrating this work with hands on, real-life application over a three-day period. To meet this goal, the team developed five simulated events focusing on team dynamics; communication, recognition, and management of emergent situations; orientation to a new environment; correct treatment processes; and proper documentation. Inter-professional Education Development to Meet Teamwork and Communication Objectives To ensure the success of this new unit, the LRU team collaborated with the Shock Trauma Center Training and Simulation Manager, Jason Bates, MA. Over the course of two months, they jointly developed a plan of instruction (POI) that identified the target audience and audience-specific performance objectives, and provided a summation of the simulated events. In addition, case scenarios, simulation-specific performance checklists, and training evaluations were developed. Logistics planning, scheduling, and coordination for the in-situ training were conducted. The scenarios developed were designed to mirror the potential LRU patient population. Checklists were utilized to monitor performance throughout each of the simulations. Given that the participating staff are all experienced health care providers, the scenarios were designed to focus on interprofessional skills and closed-loop communication. This method involves acknowledgment and repetition. For instance, after a provider gives an order, such as the administration of medicine, a nurse repeats, receives confirmation and, when administering the continued on page 7.

7 news &views 7 STC Lung Rescue Unit, continued from page 6. Day of Training Scenario 1 Decompensating patient due to a tension pneumothorax 2 Manual prone positioning of ECMO patients Sedation/Analgesia in ECMO patients Transporting ECMO patients with catastrophic incidents/ mass transfusion 3 Cannulation of an ECMO patient Inter-Professional Skills Assessed/Developed Team Dynamics Leadership Communication Personnel Management Workflow Emergent /Non-Emergent Situation Management Orientation to the Environment Treatment Processes and Protocols Documentation Number of Iterations per Team One Two One Table 1. Summary of Simulation Sessions medication, repeats once more. Some of the leadership team also attended a simulation debriefing course developed and conducted by Mary Fey, PhD, and her team of simulation experts at the University of Maryland School of Nursing. Table 1 describes the simulated patient profile, skills, and frequency of each scenario. Coordination Across UMMC Simulation Programs Kerry Murphy, DVM, simulation educator of the MASTRI Center and Robert Dibiase, BS, program coordinator of the Air Force C-STARS simulation program, supported Bates in developing a logistical plan to ensure all simulation equipment needed was available and accessible for training; creating moulage (the art of applying mock injuries for the purpose of training); integrating the patient profile with specific simulated presentations (i.e., making sure the simulated experience followed the designated scenario); and, running the three days of simulated training ensuring familiarity and continuity during the course of training. Executing the Simulated Events To create a comprehensive simulated experience that would closely resemble what a typical day might be like, the simulated events included inter-professional teams comprised of respiratory therapists, perfusionists, nurses, providers, technicians, and unit secretaries. Nursing peers from the critical care resuscitation unit (CCRU) were generous in volunteering their time and expertise toward assisting in the training. The personnel who assisted (non-participants) in the execution are listed below: Vicky Chan, RRT (ECMO specialist) Mark Bauman, MS, RN, CCRN Kristen George, RN (CCRU) Allison Giammanco, RRT Eric Hochberg, PA-C Tiffany Hogan, RRT Vanzetta James, MS, RN, CCRN Ryan King, unit secretary Louie Lee, RN (CCRU) Maria Madden, RRT Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN Adam Rabinowitz, CRNP Raymond Rector, CCP Brittany Rub, RRT The participant population was divided into three patient care teams that worked together through the simulated events. Rotating through each of the scenarios, individual participants were given the opportunity to manage the clinical situation and direct the inter-professional team during each event. In some cases, process documents were provided to assist in the management of the simulated patients and, in all cases, the teams were allowed time to discover the location of equipment and use them as they would with real patients. Practicing as they would in an actual situation, the teams soon discovered several unknown aspects of treatment that each scenario presented. For instance, identifying where and how long it would take to receive blood from the blood bank in an emergency, the process of getting unmatched blood from the trauma resuscitation unit (TRU), and identifying which elevators would allow for the transport of a patient requiring EMCO and the full complement of equipment. In essence, the teams were experiencing (and learning from) the potential pitfalls of an emergent situation without affecting an actual patient. Lessons Learned and Results from the Simulated Events Based on observations made during these simulations and validated through staff evaluations, it was apparent that staff thoroughly enjoyed and benefitted from the simulation experience. Some consistent themes emerged, both in oral and written feedback, and included the following: Trust was built and teamwork enhanced by these exercises. The social integration and familiarization with one another was just as important as the clinical skills. Absolute buy in from participants, instructors and designers was crucial if the simulations were to have a meaningful impact. Professional instruction and equipment was essential, but a presimulation briefing on the importance of running the scenario as in an actual clinical situation was just as important. The actual paging of someone or running to the blood bank was crucial in reinforcing the objectives identified. continued on page 8.

8 8 Fall 2014 STC Lung Rescue Unit, continued from page 7. Conducting the simulation scenarios in the unit s patient rooms with the actual supplies, monitors, etc. that would be used on actual patients increased environmental awareness and raised the comfort level of all participants dramatically. One of the biggest fears identified by team members in the pre simulation training was in not knowing where things were located, especially in an emergency. While not always practical, this in-situ training helped immensely in alleviating some of the anxiety in opening a new unit. During this process, we also discovered some minor issues, such as overhead lights not working, and some more problematic issues, such as the trauma elevators not being able to accommodate an ECMO transport with patient bed, IV pumps, ECMO machine, ventilator, and accompanying medical personnel. Debriefing was an important, if not the most important component of simulation training. Involving individuals with previous experience and/or theoretical knowledge of how to debrief a simulation was imperative for successful simulation training. Employing a checklist of critical objectives for consistency and asking open-ended questions, (as opposed to grading a test), allowed for constructive interchange. Providing each discipline with the opportunity to participate as they would in real life was important. Not only did it lend credibility to the scenario, but it allowed each discipline an opportunity to make adjustments where necessary to their part of the scenario, to add realism and avoid predictability. Simulated cannulation of an ECMO patient Overall, the combined efforts of those involved led to three days of very successful simulation training. The entire exercise was well received based on the enthusiasm of the team participants and the feedback that was garnered from post-simulation evaluations. Moreover, the benefit of the simulation training was reflected almost immediately. When this new unit opened the following week, several patients requiring ECMO were transferred from the CSICU to the LRU. The personnel involved in these transports commented on how the simulations provided them confidence in understanding how to safely transport their patients. Moreover, it gave them an even greater appreciation of role delegation and the importance of good communication among team members, including critical situations to avoid or mitigate. The Future of Education in the LRU The staff and leadership of the LRU believe that simulation training will serve as the foundation of a comprehensive education and training program as they strive for excellence in the care of this complex patient population. The intention is to hold simulation training on a quarterly basis, focusing on the implementation of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), to further hone skills, refine processes, and facilitate quality improvement on the unit. Moreover, by following this strategy, it is anticipated that these efforts will continue to advance the position of the R Adams Cowley Shock Trauma Center as the world leader in trauma and critical care management.

9 news &views 9 PATIENT CARE SERVICES NUTRITION Registered Dietitians Obtain Order-Writing Privileges for Nutrition Supplements via Protocol Ellen Loreck, MS, RD, LDN, Director of Clinical Nutrition Services Registered dietitians (RDs) were recently granted Medical Executive Council (MEC) approval to order nutrition supplements for pediatric and adult in-patients via protocol. What will this mean for patient care and why now? The Centers for Medicare and Medicaid Services (CMS) May 12, 2014 Federal Register proposed to revise the hospital requirement, Condition of Participation (Cop) (b)- Food & Dietetic Services, which mandated that a therapeutic diet order must be prescribed only by the practitioner or practitioners responsible for the care of the patient. 1 This regulation excluded RDs, who are highly trained to manage nutrition care. The revised standard, which went into effect on July 11, requires that individual patient nutritional needs be met in accordance with recognized dietary practices. In addition, revisions were made to allow for flexibility by requiring that all patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or other clinically qualified nutrition professional as authorized by the medical staff and in accordance with state law. The reason for the change is clearly stated by CMS: RDs are the professionals who are best qualified to assess a patient s nutritional status and to design and implement a nutritional treatment plan in consultation with the patient s interdisciplinary team. For a patient to receive timely nutritional care, the RD must be viewed as an integral member of the interdisciplinary team, one who is responsible for a patient s nutritional diagnosis and treatment, in light of the patient s medical diagnosis. The purpose of this regulatory change is to allow hospitals to grant appropriate ordering privileges to RDs to effectively capture enhanced patient outcomes and overall cost savings. 1 Consistent with the recent CMS regulatory changes, the Department of Clinical Nutrition Services developed a protocol to allow RDs to order nutrition supplements for pediatric and adult in-patients who have existing diet orders. The goal of the protocol is to facilitate timely nutrition care intervention for patients at risk for malnutrition or who are already malnourished. The protocol is simple. The statement, RD to manage nutrition supplements per protocol, is pre-selected as part of the admitting order set. Prescribers may choose to deselect the order if desired. The RD staff has pre-defined specific supplements allowed for various diet orders (Figure 1). Once the protocol is initiated, the RD may add or modify a nutrition supplement, according to the patient s clinical needs. The protocol s potential impact is consistent with two of our key strategic goals strategies: achieving optimal clinical outcomes and managing operating expenses. Based on departmental data, approximately 35-45% of our patients at the Medical Center are at risk for or are already malnourished. Available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. 2 Early and on-going management of oral supplementation is a key strategy in improving nutrition care for those who are able to eat. The RD-managed protocol should enable our busy prescribers to focus attention elsewhere while patients nutrition needs are being managed. In addition, with close RD management of supplements, supply expense should decrease. Once the nutrition supplement protocol is successfully implemented, our team intends to request an expansion of privileges to order other aspects of nutrition care, such as changing diet and enteral nutrition orders. POLICY AND PROCEDURE MANUAL POLICY: Registered Dietitian (RD) Nutrition Supplement Protocol POLICY NO: COP PAGE: 1 OF 1 LAST REVISION DATE: NEW ATTACHMENT A: CLINICALLY-APPROPRIATE SUPPLEMENTS FOR DIET ORDERS Clinically-Appropriate Supplements for Diet Orders Diet Order Clinically-Appropriate Supplements Regular Mechanical Soft Pureed Heart Healthy Neutropenic 2 Gram Sodium Boost Breeze, Boost Pudding, Carnation Instant Breakfast, Ensure Plus, Gatorade Recover, Glucerna Shake, Magic Cup, Muscle Milk, Resource Health Shake, Resource No Added Sugar Health Shake, Resource Thickened Shake Pediatric Boost Breeze, Boost Pudding, Carnation Instant Breakfast, Elecare Jr Vanilla, Ensure Plus, Gatorade Recover, Glucerna Shake, Magic Cup, Muscle Milk, Resource Health Shake, Resource No Added Sugar Health Shake, Resource Thickened Shake, Pediasure, Pediasure 1.5 Cal, Pediasure Peptide 1.0 Cal, Pediasure Peptide 1.5 Cal, Suplena w/carb Steady Clear Liquid Boost Breeze, Gatorade Recover Adult Diabetes: Consistent Carbohydrate Glucerna Shake (<30 g cho/svg) Gestational Diabetes Mellitus (GDM) Glucerna Shake (<30 g cho/svg) Thickened Liquids: Honey (part of any diet order) Boost Pudding, Resource Thickened Shake; Magic Cup Thickened Liquids: Nectar (part of any diet order) Boost Pudding, Resource Thickened Shake, Magic Cup Low Lactose Boost Breeze, Boost Pudding, Ensure Plus, Gatorade Recover, Glucerna Shake, Muscle Milk, Resource Thickened Juice 2 Gram Potassium/or Low Phosphorus Nepro Carb Steady Low Fiber Boost Breeze, Boost Pudding, Magic Cup, Resource Health Shake, Resource No Added Sugar Healthshake, Resource Thickened Shake (<2 g fiber /svg) Low Fat (50 g) Boost Breeze, Carnation Instant Breakfast w/skim Milk, Gatorade Recover (< 3 g fat/svg) Roux 1, 2 or 3 Optisource Wired Jaw 1 or 2 Boost Breeze, Carnation Instant Breakfast, Ensure Plus, Gatorade Recover, Glucerna Shake, Magic Cup, Muscle Milk, Resource Health Shake Figure 1 References 1. Federal Register / Vol. 79, No. 91 / Monday, May 12, 2014 / Rules and Regulations. 2. Tappenden KA, Quatrara B, Parkhurst M et al. Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition. JPEN. 2013; 37(4):

10 10 Fall 2014 Cardiac Electrophysiology Lab The Shocking Truth Johnathan Klaus, BS, RN The cardiac electrophysiology (EP) lab is a service located on the third floor of the North Hospital. It academically resides in the division of cardiovascular medicine, under the Department of Medicine. Currently, there are two procedure rooms that encompass the EP lab. The first is the primary device lab, where implantations of implantable cardioverter defibrillators (ICDs), pacemakers, and event monitors take place. The second is a lab that is used primarily for electrophysiology studies and cardiac ablations. It contains two 3-D mapping systems to provide detailed images of the heart during complex cardiac ablations. The staff comprises 10 nurses, one device nurse, one research nurse coordinator, five attending physicians, and two fellows. In addition, there is a pediatric electrophysiologist that performs studies and ablations. The device nurse is a role that was created in 2012 to handle a growing volume of pacemaker and ICD diagnostic evaluations within UMMC. Their responsibilities include evaluating cardiac devices at the request of physicians, responding to the operating rooms to change settings before and after surgery, and following patients who have remote home transmitters to monitor their cardiac devices. The device nurse is available to provide in-services for staff about the different devices and how they can affect telemetry monitoring. There is also a research nurse who coordinates and oversees 29 active research studies currently taking place in the EP lab. Beginning in December of this year, both labs will be upgraded with new fluoroscopy equipment, as well as upgraded mapping systems. We look forward to working with our fellow nurses and physicians in the cardiac catheterization lab as we will be sharing some of their space while our renovations are under way. Types of procedures conducted in the EP lab Pacemaker and ICD implants During fiscal year 2014, the EP lab implanted 405 pacemakers and ICDs. Most of these devices were implanted in the chest, with leads for pacing and shocking fed through the veins and into the heart, where they are screwed into place. A pacemaker is a device that is designed to speed the heart up if it is going too slow. An ICD is a device that is designed to shock the heart out of a fast rhythm, such as ventricular tachycardia. It can also pace the heart in the event of a slow rhythm. These devices have become smaller and the batteries that are used are lasting much longer up to ten years. A new ICD device that was recently released does not involve placing any leads into the heart. The lead is inserted just under the skin, with the ICD itself implanted in the left axilla, just under the rib cage. For certain patients, this type of device can dramatically reduce the risk of an infection in the heart. Size comparison of a pacemaker and an implantable cardioverter defibrillator Implantable event (or loop ) recorders Event recorders are implanted just under the skin and monitor the heart for arrhythmias. They are used in cases where no arrhythmias are found during testing, and for unexplained syncopal episodes. Patients are given a home transmitting unit. If any cardiac arrhythmias are detected, the transmitter will automatically send a report to the device nurse who, if needed, will have an electrophysiologist evaluate it. Recent medical advances have made the size of these devices much smaller. Prior to February 2014, they were the size of a pack of chewing gum; today they are about the size of a paper clip. Size comparison of old (left) and new (right) implantable event recorders continued on page 11.

11 news &views 11 Cardiac Electrophysiology Lab, continued from page 10. Tilt table tests These tests are designed to check for neurocardiogenic syncope, also called vasovagal syncope. This occurs when the nervous system sends a signal to one s heart to slow down, resulting in a drop in blood pressure and causing the person to lose consciousness. This test first involves placing a patient on a special table, securely fastening them to the table, and then raising the table to 70 degrees for 20 minutes. Isoproterenol is given and titrated to achieve a 20% increase in heart rate, with the patient kept elevated for another 20 minutes. Heart rate and blood pressure are continuously monitored by a nurse. If the person does not lose consciousness, other options, such as an event recorder or an EP study, are considered. To check for seizure activity as a possible cause, the test can be conducted while the patient is connected to a continuous electroencephalogram (EEG). Kathy Lynch, BSN, RN, demonstrates how a patient is positioned on the tilt table, raised to 70 degrees. Electrophysiology studies and cardiac ablations In fiscal year 2014, the EP lab completed 363 EP studies and cardiac ablations. Basic EP studies involve accessing the femoral veins and feeding catheters with platinumtipped electrodes into the heart. The heart is then stimulated at various points to try and illicit an arrhythmia. Cardiac ablations are undertaken to eliminate a heart arrhythmia. Numerous ablations are performed much like the EP studies, except one of the catheters will generate heat using radio frequency, to cause scarring on the portion of the heart that is causing the arrhythmia. More complex ablations include ventricular tachycardia and atrial fibrillation ablations. These studies involve the use of 3-D mapping systems to provide a complete image of the heart during the ablation procedure. Many of these complex ablations can involve puncturing through the septum of the heart to properly place the catheters. Inside Lab 2. The fluoro system is visible with the primary camera and biplane; the 3-D mapping system and ablation controls can be seen on the rear wall. The EP lab staff is fortunate to have good working relationships with colleagues in other areas of the medical center. Many of their outpatients require sedation for their procedures. They are prepped and recovered in the cardiac prep and recovery unit. While most of the procedures are carried out using moderate sedation administered by a nurse and supervised by a physician, some patients may need a deeper level of sedation. For these patients, the EP lab nurses and physicians work closely with an anesthesiologist to provide sedation or general anesthesia, whichever is deemed appropriate and safe. In addition, staff work with colleagues in the department of echocardiography to provide support for transesophogeal and transthoracic echocardiograms. Through this collaboration with other procedural units and advances in technology, the EP lab has been able to grow and expand, providing more comprehensive care and treatments to their growing patient population.

12 12 Fall 2014 PATIENT CARE SERVICES RESPIRATORY CARE Surgical and Neuro ICUs, Expanding Areas for Respiratory Care Christopher D. Kircher, MS, RRT-ACCS, and Marlin Martin, RRT The growth of the surgical and neuro intensive care units (ICUs) has necessitated an intensified approach with additional staff support and targeted education by Respiratory Care Services. Increases in ICU beds typically mean an increase in ventilator utilization and the many airway clearance modalities that are required to lead patients back toward spontaneous breathing. This growth has led to an increased opportunity for our respiratory therapists to provide better patient care and support for fellow staff working in these clinical areas. Enhanced staffing has most recently come in the form of 24 very enthusiastic and capable newly hired respiratory therapists, who joined our department in July As is the case with all University of Maryland Medical Center (UMMC) respiratory therapists, orientation starts with a three-week classroom session where all policies, equipment competencies, and treatment methodologies are discussed. The clinical phase of orientation continues with seven weeks of supervised rotation though all adult areas. This practice allows learning to build in a controlled fashion, rather than all at once in the clinical environment. Following this 10-week program, staff continue to gain hands-on experience in units where they are partnered with an additional two or three therapists. For these new UMMC therapists, the many adult ICUs provide a wide variety of patient care opportunities and ventilator support experiences. During these early weeks, it is always important to stress the need for strong interdisciplinary communication, to help assure the smooth application of several patient pathways, and the overall support of an established plan of care. In 2014, the SICU provided a focused partnership with several projects that reduced the cost of resources and increased the efficiency of patient care. The first began as a proposed cost savings endeavor in conjunction with the critical care operations committee. Denise Choiniere, MS, RN, director, materials management and sustainability, and Paul Ricks, manager, distribution and logistics, worked with Marlin Martin, RRT, supervisor, respiratory care, and Meredith Huffines, MS, RN, senior clinical nurse II, in the surgical intensive care unit (SICU), to trial several oxygen conservation devices. Staff had the hands-on opportunity to comment and provide feedback about design and ease of use. At the completion of the trial, official suggestions were presented through the value and analysis committee with support from Allison Murter, MSN, RN, lead, clinical practice and professional development coordinator, and Victoria Stewart, MBA, director, business operations, perioperative and endoscopy services. Now installed at all ICU and intermediate care (IMC) bedsides, this oxygen eliminator device allows for oxygen flow when a manual resuscitation bag is in use, and stops flow when in the stand-by position. The cost of the purchase was projected to pay for itself over several years through the savings in bulk oxygen supply costs. Respiratory care was able to help identify a product that would provide a significant cost savings to UMMC, says Martin. Through value analysis, the critical care operations committee, and a collaboration between materials management, SICU nursing and respiratory care, we jointly selected a product that benefited both our patients and reduced cost. The entire process served as an excellent example of multiple departments working together on a joint effort. The second was the introduction of a new mechanical ventilator platform, which stressed the need for strong interdisciplinary collaboration and regular education support. The respiratory therapists were well prepared following the department s fall competency marathon, with the nursing and physician teams supported by education sessions held on the unit. Currently utilized through the trauma ICUs and the SICU, this new platform will help Left to right: Carmen Hazera, RRT; Marlin Martin, RRT; and Mary Ann Bautista, MS, RN provide a safer and more versatile method of artificial respiration through enhanced alarm features and modes of ventilation that help wean support through closed-loop, algorithm-supported software. Moving into 2015, we will continue to work with the Rise and Shine committee to decrease overall ventilator length of stay through combined sedation management and daily spontaneous breathing trials. Samuel Tisherman, MD, FACS, FCCM, continued on page 13.

13 news &views 13 Certification Corner CNOR Certification for the Operating Room B. Jane Redwood, RN, CNOR, education coordinator, Trauma OR Working in the trauma operating room is a unique experience that requires the nurse to be proficient as a circulator and scrub nurse. This is not always the case in other general OR, where these positions are often filled by two distinct individuals. With this combined responsibility, the nurse may have the opportunity to care for patients with a broad range of ailments from an open femur with vascular damage due to a motor vehicle accident, to an epidural hematoma as a result of a serious fall. Achieving CNOR certification is critical for any nurse practicing in this environment. This program is for perioperative nurses interested in improving and validating their knowledge and skills and providing the highest quality care to their patients. Not only does the nurse need to safely practice in the operating room, but they need to understand the entire perioperative experience from pre to post surgery. This includes a more in-depth understanding of the pharmacological and anesthesiology components of caring for a patient, as well as gaining a greater knowledge and appreciation for the complex equipment and instrumentation that are used in the ORs. The certification process takes all of these areas into consideration and prepares the nurse in the standards and recommended practices as conveyed by the Association of perioperative Registered Nurses (AORN) and other governing bodies. UMMC is fortunate to have leaders in the perioperative setting who understand the importance of further education and who support their staff in pursuing this specialty certification. To take the exam, a candidate is required to have a valid nursing license, be working in the perioperative area, and have completed a minimum of two years in the perioperative setting with no less than 50 percent being in the OR. Preparation for the exam does not have to be daunting as there are many materials and tools, including study guides, webinars and flash cards, available through the Competency and Credentialing Institute (CCI) and AORN. Moreover, OR nurses often come together to study in groups, with everyone helping each other to meet the same goal. The regular price for the exam is $385; however, for AORN members, the cost is $310. All UMMC OR nurses are members of AORN and their membership fee is paid for by the institution. The cost of taking the exam is covered by the education benefit. Certification in the operating room is also available for the scrub technicians. Their certification is through the Association of Surgical Technologists (AST) and the National Center for Competency Testing (NCCT). Once certified, it allows the scrub technician to work towards a similar clinical ladder as nurses and ultimately be in a leadership position for their group. The CNOR certification is valid for five years. During this time, the nurse must partake in additional educational offerings to stay abreast of the ever-changing environment of the ORs. They may recertify in one of the following ways: 1. Contact hours 2. Points 3. Exam 4. Portfolio As of this writing, the trauma ORs have 15 certified nurses and 10 certified scrub technicians. For further information, please go to the Competency and Credentialing Institute s website at Respiratory Care, continued from page 12. and medical director for the SICU, commented, Respiratory therapy s commitment to being an integral part of the multidisciplinary care team is very impressive. Therapists are available, on the spot, to provide immediate interventions that improve the care of our patients. I look forward to partnering with respiratory care in completing the implementation of our new Drager V500 ventilators. In past years, the neuro ICU was often a paired respiratory assignment with another ICU or IMC. The expansion of neuro care beds into both the east and west sides of the Gudelsky building has provided an opportunity to dedicate respiratory therapists to this one area. This allows for more continuous support, regular participation in physician rounds and increased collaboration with nursing staff. This became most beneficial when an opportunity arose for respiratory care to build a competency for the manipulation of extraventricular drains (EVDs), since many of the procedures respiratory therapists routinely provide require that manipulation. Mary Ann Bautista, MS, RN, clinical educator for neuro critical care, worked with Martin and Carmen Hazera, RRT, staff respiratory therapist, to build a proficiency station for the 2013 respiratory care annual competency marathon. This education and competency testing increased the overall understanding of intracranial pressure monitoring, the importance and process for safe drain management, and facilitated a more comfortable partnership with our nursing peers. The growth of our facility has presented challenges for the respiratory therapists. Though many policies and procedures are transferrable between clinical areas, each new ICU requires some form of unique support. There is a dedication among the respiratory care management team in support of the staff respiratory therapists, to provide the necessary training and competency development to meet these ever-changing needs. Whether it is the care of specific patient populations or the special skills related to advanced support equipment, the respiratory care department at UMMC will continue to raise the bar for professional practice and, in turn, provide the best possible care for our patients.

14 14 Fall 2014 New Process Streamlines Product In-Services Erin O Grady, MS, RN, OCN, CNL, and Tia Milburn, BA In May 2014, staff from clinical practice and professional development (CPPD) developed and launched a new process for in-service education on medical products that are used on all patient care units. This initiative was a result of feedback from nursing leadership, unit educators, and staff nurses who reported that vendors would often arrive unannounced on units to conduct product in-services. As one might expect, staff were not always prepared to receive these visitors. Moreover, vendors often provided education that they thought was best for the unit without prior consultation from a clinical education specialist. This increased the potential for the delivery of wrong information and misunderstanding regarding the proper way to use these products. In response to these concerns, a new process was established that allows the Medical Center s education experts to (1) determine the usefulness and validity of the in-service; (2) ensure that the product is currently in use and will remain in use; and, (3) create a schedule so that unit leadership can assist in coordinating patient care during the expected time of the inservice. This process assists in streamlining education for nursing staff, reducing the incidents of unannounced vendor visits on the units, and managing requests from multiple units requiring in-services on the same products. As a result, staff can simultaneously be informed when educational opportunities for products are scheduled so that all who have an interest can partake in these offerings. Furthermore, to streamline communication between vendors and units, a standardized was developed to help unit leaders quickly determine whether the education was a priority for their unit/department. In addition, feedback had been received that unit leaders would like to receive an notification in which they could easily recognize the in-service content. To accommodate this request, the new process for sending out correspondence includes a subject line announcing an in-service opportunity Product Refresher Training: Product Name. Figure 1 outlines the new process. continued on page 15. Unit Requested Product InIn-Services Vendor Requested Product InIn-Services Unit r ve locates and completes the Unit In-Service Request Form available on the UMMC Insider. Vendor r ve requests, completes, and submits the Vendor In-Service Request Form via through Clinical P & Professional Development (CPPD). Unit r ve submits Unit In-Service Request Form to Clinical P & Professional Development (CPPD) via . Upon receipt, CPPD edu on specialist submits vendor s requested product in-service to UMMC edu on experts for approval to proceed with requested in-service. Upon receipt, CPPD edu on specialist contacts the product s vendor represen to secure a meframe for product in-service. Upon approval, CPPD edu on specialist contacts the product s vendor represen to secure a meframe for product in-service. CPPD education specialist contacts the unit leadership of all UMMC units to provide notice of the scheduled in-service, offering an opportunity for others to receive in-service education. A final schedule is developed and shared with all participating unit leaders. Scheduled in-services are held and evaluated on participating units. Figure 1

15 news &views 15 New In-Services Process, continued from page 14. Prior to the in-services, education experts discuss the following information with the vendor representatives: UMMC s vendor relationship policy; The educational goals and objectives; UMMC s current use of the product; and The schedule for the product in-service. This review helps to ensure that the clinical staff receives appropriate education regarding the products. The education is offered at multiple times during the day and night shifts to maximize the number of participants. In the course of these in-services, vendor representatives collect sign-in sheets and evaluations (to assess the product and the vendor s in-servicing performance) and return them to clinical practice and professional development. This is to ensure all staff required to participate in one or more of these sessions have their attendance recorded in their Healthstream transcript and that feedback is evaluated to help improve future in-service events. This new evaluation process has recently been applied to products such as Flexiseal, Alteplase, V.A.C., and Comfort Shield barrier cloths. After an in-service occurs, the participant is asked to rate from 1 to 5 (with 1 representing not at all and 5 representing very well ) how well they can: describe the product s purpose, and verbalize or demonstrate the product s appropriate use. In addition, staff is asked to evaluate (on the same scale of 1 to 5) how well the vendor s product education was carried out. Evaluation data from the recent Flexiseal in-service showed that the average score for explanation of product purpose and use was For an assessment of the vendor s delivery of material, scores ranged from 4.89 to These numbers clearly demonstrate that, in this instance, useful product education was conducted in an effective manner. For the future, the goal is to continue to utilize and evaluate this process. It is important that all staff follow this new process to remain compliant with hospital guidelines. For questions, please contact Clinical Practice & Professional Development at or ProfessionalDevelopment@umm.edu. Additional Note: The process for vendor in-servicing for product trials, initial training, and product exchanges will remain the same and correspondences for in-services will continue to be sent by Donna Huffer, MA, BSN, RN, OCN. Your take 3 for vendor in-services 1. To request an existing product in-service, access the following link on the Insider: nursing/cppd/clined/current-product-vendor-in-services. TEAM MANAGEMENT OF DIABETES SAVE the DATE March 10, 2015 UNIVERSITY OF MARYLAND BALTIMORE SOUTHERN MANAGEMENT CORPORATION CAMPUS CENTER Conference to be held at the University of Maryland Baltimore Southern Management Corporation Campus Center 621 W. Lombard Street Baltimore, MD It is important that staff participating in existing product in-services print their name legibly on sign-in sheets to receive credit on their Healthstream transcript. 3. Unit leadership should be on the lookout for s notifying them of in-service opportunities.

16 16 Fall 2014 Achievements Excellence in Clinical Practice Award Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN Congratulations to Sue Pugh, MSN, RN, CNS-BC, ARNP, CRRN, CNRN, FAHA, clinical nurse specialist for Shock Trauma Acute Care and the Shock Trauma Outpatient Pavilion, who was selected by the American Heart Association s Council on Cardiovascular and Stroke Nursing as this year s winner of the Excellence in Clinical Practice Award. This prestigious award recognizes an active member of the Council on Cardiovascular and Stroke Nursing for excellence in cardiovascular nursing clinical practice; meeting standards of professional performance articulated by the American Sue Pugh, MSN, RN, CNS-BC, ARNP, CRRN, CNRN, FAHA, and colleague, Ellen Arnold, BSN, RN Heart Association; contributions to the professional development of peers, colleagues and others; ethical decisionmaking and actions on behalf of patients; collaboration with patients, families and other health care providers; and, scholarship in cardiovascular and stroke nursing. With over twenty years of experience working with stroke patients and their families, Sue has worked tirelessly to drive excellence in the care provided to these types of patients. She has presented posters and lectures on evidence-based practice related to the care of stroke patients at regional and national meetings. Sue has authored numerous publications related to stroke care, including having served as co-author on an American Heart Association scientific statement focusing on stroke rehabilitation. In addition, Sue has been active in multiple professional organizations, recently serving on the board of directors for the American Association of Neuroscience Nurses, and as the current chairperson of the Council on Cardiovascular Nursing Stroke Nursing Committee of the American Heart Association/American Stroke Association. For her work in improving patient safety, Sue was awarded the 2012 Distinguished Achievement in Patient Safety Innovation Award from the Maryland Patient Safety Center. We thank Sue for her consistent contributions to improving the quality of care for stroke patients and their families. Again, congratulations on this well-deserved Excellence in Clinical Practice Award. Congratulations to the following UMMC nurses promoted in July 2014! Senior Clinical Nurse I Kirsten Head, BSN, RN, CCRN Medical Intensive Care Unit Chelsea Ruch, BSN, RN Adult Emergency Department Barbara Bosah, BSN, RN Surgical Intermediate Care/Surgical Progressive Care Unit Lydia Moges, BSN, RN, CCTN Transplant Chad Caldwell, BSN, RN, CCRN Critical Care Resuscitation Unit Hannah Entwistle, BSN, RN, CCRN, FCCS Medical Intensive Care Unit Nicole Hodski, BSN, BS, RN, CCRN, FCCS Medical Intensive Care Unit Christy Callahan, BSN, RN Psychiatric Emergency Services Senior Clinical Nurse II Jean Ludwig, MS, RN, CCRN, CPAN General Post Anesthesia Care Unit Cheryl Coale, BSN, BS, RN, CCRN, FCCS Medical Intensive Care Unit Kelly Ulloa, BSN, RN, CEN Adult Emergency Department Holli Weaver, BSN, RN, CPEN Pediatric Emergency Department M. Tracey Penaloza, BSN, RN, CNOR PeriOperative Services Gloria Dzukey, BSN, RN, PCCN Neurotrauma Intermediate Care Unit

17 news &views 17 UM School of Nursing Visionary Pioneer Awards Honor Lisa Rowen Two Earlier UMMC Nurse Leaders Honored Posthumously Lisa Rowen, DNSc, RN, FAAN, senior vice president for patient care services and chief nursing officer at UMMC, is one of 25 outstanding alumni of the University of Maryland School of Nursing (UMSON) to be honored by the school with its inaugural Visionary Pioneer Award. Two earlier UMMC nurse leaders, Elizabeth Scanlan Trump, MS, RN, and Ethel Palmer Clark, DIN will be honored posthumously with Visionary Pioneer Awards, which will be given at the school s 125th anniversary celebration April 18. The awards recognize alumni for significant contributions to the profession through entrepreneurship, innovation, and leadership. All of these outstanding alumni have had an impact on the nursing profession and health care, and we are extremely proud of them, said Jane M. Kirschling, PhD, RN, FAAN, dean of the School of Nursing. Rowen: A Visionary and Transformational Leader We are incredibly fortunate to have such a visionary and transformational leader at UMMC, said Jeffrey A. Rivest, president and chief executive officer of UMMC who nominated Rowen for the award. Lisa has an impressive history of advocating for nurses and the valuable roles they fulfill in all aspects of health care, Rivest said. She is a catalyst for advancing excellence in patient care and a tireless advocate for the role of teamwork in patient safety. Lisa has led us to Magnet designation and re-designation and forged valuable partnerships with the School of Nursing. As an accomplished and compassionate health care leader, expert nursing educator and sought-after mentor, she is truly deserving of this award. Since becoming chief nursing officer at UMMC in 2007, Rowen has been instrumental in building a partnership with the UMSON to bring nursing education and clinical practice together with a vision to optimize patient outcomes by enhancing nursing practice. Rowen earned her Doctor of Nursing Science degree from Johns Hopkins University (JHU) and served as director of surgical nursing at Johns Hopkins Hospital before coming to UMMC. She is an associate professor at the UMSON and also holds faculty appointments at the schools of nursing at JHU, the University of Virginia and Northeastern University in Boston. It is an honor to be one among a group of such esteemed colleagues, said Rowen, who earned her master s degree at the UMSON. The University of Maryland School of Nursing gave me the knowledge and tools to guide my own practice and to contribute to advancing the profession. Trump: The Mother of Trauma and Critical Care Nursing The list of UMSON Visionary Pioneers includes a revered UMMC nurse leader, honored posthumously. Elizabeth Scanlan Trump, who died in 2012, is considered the nation s first trauma nurse and the mother of trauma and critical care nursing. She first came to UMMC in 1957 just after graduating from the St. Agnes Hospital School of Nursing, continuing her graduate work at the UMSON to earn a master s degree in She collaborated with R Adams Cowley, MD, to develop the new model that became the R Adams Cowley Shock Trauma Center one of the preeminent trauma centers in the world. She was the first director of nursing at Shock Trauma and led the nursing team until her retirement in She was instrumental in publishing the first trauma and critical care nursing textbook, Trauma Nursing, From Resuscitation to Rehabilitation. Liz was the mother of trauma nursing and now there is an elite cadre of trauma nurses across the world because of her, said Karen E. Doyle, MBA, MS, RN, NEA-BC, vice president for nursing and operations at the Shock Trauma Center, who nominated Trump for the award. She was driven, tenacious and tough, and came from a time when nurses were handmaidens and subservient, but Dr. Cowley treated her as a full partner. She set the stage more than 40 years ago and was a true visionary. Clark: an Early Nursing Pioneer Another posthumously honored nurse leader to be recognized is Ethel Palmer Clark, who received her graduate degree from the School of Nursing in 1906 and became the superintendent of what was then called University of Maryland Hospital from She went on to be a leader in nursing education at Indiana University and was instrumental in forming Sigma Theta Tau International Honor Society of Nursing. A full list of winners is available on the UM School of Nursing website. Achievements continued on page 18.

18 18 Fall 2014 Achievements, continued from page 17. UMMC Earns Award for Excellence in Care of Patients Needing ECMO UMMC has earned the ELSO Award for Excellence in Life Support for 2014 from the Extracorporeal Life Support Organization (ELSO), based in Ann Arbor, Michigan. The award distinguishes UMMC as a Center of Excellence for care of patients requiring extracorporeal membrane oxygenation (ECMO) for heart and lung failure, and is valid for the next three years. This prestigious honor recognizes our excellent team for being among the best in the world in caring for some of the most critically ill patients, said Lisa Rowen, DNSc, RN, FAAN, senior vice president for patient care services and chief nursing officer. The ECMO machine serves as a bridge to recovery for patients with acute lung failure from pulmonary disease, oxygenating organs so they can heal. ECMO is a major lifesaving tool for many of UMMC s heart-lung transplant candidates. The machine will provide support to the patient s failing organs until a suitable donor is found and the patient is able to undergo a transplant surgery. ECMO is a clinical service differentiator patients can t get it at just any hospital. This type of care requires a multidisciplinary team of extremely skilled staff in the critical care units where ECMO patients are cared for primarily the cardiac surgery intensive care unit (CSICU), the pediatric intensive care unit (PICU) and the newly opened lung rescue unit (LRU). Perfusionists are the professionals who assist the physicians with the initiation of the ECMO machine and collaborate with the physician/nurse practitioner/physician s assistant and the clinical nursing team to manage the minute-to-minute care of the patient at the bedside. Respiratory therapists, physical therapists, clinical pharmacists, clinical nutritionists, and others on the UMMC care team also have extensive training and experience in this highly specialized technology and bedside care. It takes a dynamic team of experts to care for these complex patients, said Tina Cafeo, DNP, RN, director of medical and surgical nursing at UMMC. We are extremely fortunate to have this team of professionals at UMMC. According to the ELSO, the award means the Medical Center has demonstrated extraordinary achievement in evidencebased patient care by using the highest quality measures, and excellence in training, education, collaboration, and communication, contributing to a healing environment for families, patients and staff. The award committee noted that UMMC was noteworthy for a comprehensive application that details an ECMO Figure 1 program with great education, quality and family-centered care. In all categories, UMMC exceeded the average score for other medical centers chosen as Centers of Excellence. (Figures 1 & 2) This award exemplifies what all-hands-on-deck multidisciplinary care can do for extremely ill patients who are precariously balanced between life and death, said Daniel Herr, MD, associate continued on page 19. Figure 2

19 news &views 19 Clinical Education Council: When Change Impacts the Delivery of Patient Care Maureen Archibald, MS, RGN, RMN, RN, Lead Clinical Education Specialist, Clinical Practice and Professional Development New products, policy updates, and changes in practice from each clinical department have the potential to impact the delivery of safe and effective patient care. To ensure that these changes are implemented in a time-sensitive, comprehensive, and inclusive manner, the Clinical Education Council (CEC) is here to help. Who are we? The CEC is a multidisciplinary group that provides consultation, support, and facilitation for any and all changes that have the potential to impact the safe and effective delivery of patient care. The council works very closely with the Clinical Practice Council to translate evidence-based care to the bedside. To assist our Council in identifying educational needs, several permanent subgroups exist, which include the Ongoing Education Subgroup, Orientation Subgroup, Graduate Nurse Advisory Committee, and the Code Blue Committee. These groups often partner with the Clinical Practice Council and will convene, when necessary, ad-hoc subgroups to assist with other education events. What can we do for you? The CEC can provide an assessment of impact, identify structure, timelines, and supportive frameworks to ensure that a proposed change targets the right audience and is quickly embraced into the safe and effective delivery of patient care. What can you do? Contact the CEC leadership as soon as you have a concept, a change in practice/policy/procedure, an identified educational need, or a new drug or product that will impact patient care. We will assess with you the touch points for the information and help structure the most effective platform for your message. Timelines Educational event support: CEC leaders (see right) two months in advance to meet and be placed on the Council s agenda. Ongoing education topic: Must be complete and ready for distribution by January 1 for the spring education marathon and August 1 for the fall education marathon. Representatives from all departments are welcome to join the group. The more departments that are represented, the more effective we all can be in delivering safe, effective, evidence-based care to all our customers. The CEC meets on the third Monday of each month from 8:30 am to 10:30 am in the Round Room, located on the third floor of the Weinberg Building. Contacts Chair: Sandra Lovelace, BSN, RN, CCRN-CSC Clinical Nurse Educator, Cardiac Surgery Intensive Care Unit slovelace@umm.edu Chair Elect: Lisa Malick, MS, RN, OCN Nurse Coordinator, Greenebaum Cancer Center lmalick@umm.edu CNS Support: Karen McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN Clinical Nurse Specialist R Adams Cowley Shock Trauma Center kmcquillan@umm.edu CPPD Facilitator: Maureen Archibald, MS, RGN, RMN, RN Lead, Clinical Education Specialist Clinical Practice and Professional Development marchibald@umm.edu Achievements, continued from page 18. professor of medicine and medical director of the CSICU. We have really great teamwork, where everyone has an important role. ECMO is an incredible technology that we are fortunate to offer patients at UMMC, said Raymond Rector, CCP, LP, perfusionist and ECMO manager. Rector compiled much of the documentation to apply for this award from the ELSO. The ECMO machine acts as an external heart/lung machine that breathes and provides cardiac support for the patient, allowing his or her heart and lungs to recover either to the point of eligibility for a transplant or full recovery for hospital discharge, Rector said. This designation is something to be very proud of, said Herr. In addition to exceeding the expectations of ELSO, our team has also documented improved patient outcomes over the last four years for patients on ECMO. Patients now have a shorter average length of stay and higher survival rates as they recover from these extreme heart and lung ailments.

20 20 Fall 2014 UMMC Employee in the News Karen A. McQuillan, MS, RN, CNS-BC, CCRN, CNRN, FAAN, lead clinical nurse specialist for the R Adams Cowley Shock Trauma Center and the American Association of Critical Care Nurses (AACN) president-elect, attended an invitation-only event at the White House regarding the Ebola response. Below is a letter written by the current president of AACN and published in October about the event. October 29, 2014 Dear Colleagues, I have exciting news to share AACN was invited to the White House. Earlier today, my colleague and our AACN president-elect, Karen McQuillan, RN, MS, CNS-BC, CCRN, CNRN, FAAN, participated in an invitation-only dialogue with top officials, where she conveyed the concerns, lessons learned and courageous work you have shared with us over the past month. AACN was one of only a few professional nursing organizations that attended this meeting with the new Ebola Response Coordinator Ron Klain and other officials working on the Ebola response. We were at the table with leaders from the American Nurses Association, the Emergency Nurses Association and the Association of Public Health Nurses. Mr. Klain set the meeting specifically to hear directly from nurses and first responders about the issues they are facing in the Ebola response. Karen shared concerns voiced by AACN community members and emphasized our commitment to support the powerful collaboration needed between bedside nurses, nursing leadership and hospital administration to ensure patients are well cared for and that nurses are safe in providing that care. At the meeting s conclusion, Mr. Klain pledged his commitment to support the work we are doing and extended an open invitation for AACN s leadership to remain in direct contact with him as the situation evolves. Following this meeting, Karen was invited to attend a briefing by the president of the United States where he thanked U.S. healthcare workers who are fighting Ebola and asked everyone to honor them as: American heroes a shining example of what America means to the world, of what is possible when America leads. We continue to monitor the most up-to-date authoritative resources and protocols so we can promptly make them available to you. We encourage you to keep informed by visiting the AACN Ebola Web page, as it is continuously updated with this information. We deeply appreciate your feedback over the last several weeks, because it has helped us know what is needed most. And I thank you for the important work you do every day caring for patients and their families, and each other. Sincerely, Teri Lynn Kiss, RN, MS, MSSW, CNML, CMSRN AACN Board President

21 news &views 21 SPOTLIGHT ON PHARMACY Investigational Drug Services at the University of Maryland Medical Center Andrew Phan, PharmD, investigational drug specialist In 1937, the first wonder drug, sulfanilamide, was marketed in America as a treatment for strep throat. It contained diethylene glycol (anti-freeze). Over 100 people died after using it and, as a result, Congress enacted the 1938 Food, Drug and Cosmetic Act. 1 This set the foundation for Food and Drug Administration (FDA) oversight that is crucial to modern drug development. A new drug on the market today must pass through phase 1, phase 2, and phase 3 clinical trials to meet safety and efficacy standards set by the FDA. 2 The University of Maryland Medical Center (UMMC) has over 200 ongoing clinical trials in all three phases. New drugs used in clinical trials are acquired, stored and dispensed by the Investigational Drug Services (IDS) pharmacy. The primary role of the IDS is to ensure clinical trial compliance with federal, state, and institutional regulations. Drug storage, security, labeling, and inventory management must adhere to FDA Good Clinical Practice (GCP) Guidelines. 3 Drug sponsors the pharmaceutical companies that provide the new drug also have their own standards and rules regarding receiving, storing, preparing, and dispensing. Additionally, The Joint Commission (TJC) publishes standards for investigational drug storage and safety. TJC guidelines require that the IDS pharmacy controls the storage, dispensing, labeling, and distribution of investigational drugs. A recommendation from the American Society of Health-System Pharmacists (ASHP) reinforces this rule, but exceptions can be made with sufficient reason and IDS oversight. 4, 5 To ensure compliance standards are met, the IDS develops summaries and guidelines for each study protocol. These guidelines provide drug and clinical trial information to all health professionals who will be dispensing the drug, and outline the proper process for preparing and dispensing the drug. Other IDS responsibilities include inventory management, randomization, blinding, and dispensing. In many blinded studies, the IDS will be the only member of the study team to know whether the patient is receiving active drug or placebo. In these cases, the IDS will coordinate randomization, accountability, and drug preparation to ensure patients and study personnel remain blinded. Before dispensing any study medication, the IDS must receive a copy, or verification of, the informed consent form signed by the study subject. The IDS is not involved in the patient consent process. Informed consent is acquired by study coordinators and investigators. This process is strictly defined by the Code of Federal Regulations. Human research standards require that the patient be well-informed of the benefits and risks of the study. 6, 7 Patients must be made aware that any procedures or treatments are voluntary. 8 The consent must be documented with a written form approved by the Institutional Review Board (IRB), and signed by the subject or a legal representative. 9 The informed consent process ensures that the patient understands the study and will be able to actively participate in their own care. Although many of its functions lie in regulatory or accountability procedures, the IDS provides other less apparent benefits. In a health care environment plagued by rising product and service costs, the IDS facilitates cost avoidance. Study-related interventions use drugs supplied by the study sponsor at no cost to the patient or health system. These are dollars saved that otherwise would have been used to purchase medications and services. In two separate studies, investigators found significant drug cost savings due to cost avoidance. The University of Washington Medical Center avoided $2,709,662 in costs during fiscal year At the University of Utah Health Systems and Clinics, cost avoidance totaled $5,088,668 during fiscal years These cost savings were passed down to patients, in many cases increasing access to care and improving patient outcomes. Investigational drug services is a unique aspect of the health system and provides specialized services to a narrow population of patients. Those services deliver clear economic, medical and regulatory benefits. As a major academic institution and research center, UMMC actively pushes the boundaries of modern medicine; the number of clinical trials here is constantly growing. As research at the Medical Center continues to expand, so too will the IDS pharmacy. References 1. Junod, Suzanne. About FDA. FDA and Clinical Drug Trials: A Short History. 7 July Web. 6 Oct Drugs. The FDA s Drug Review Process: Ensuring Are Safe and Effective. 28 May Web. 6 Oct Food and Drug Administration. International conference on harmonization: good clinical practice consolidated guidelines. Fed Regist. 1997; 62: Medication Management. Sec. 1. In: Comprehensive accreditation manual for hospitals: the official handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2004: MM Guidelines on clinical drug research. In: Deffenbaugh JH, ed. Best practices for health-system pharmacy: position and guidance documents of ASHP, Bethesda, MD: American Society of Health-System Pharmacists; 2002: Regulatory Information. A Guide to Informed Consent. 25 June Web. 6 Oct Protection of Human Subjects, 21 C.F.R (2014) 8. Protection of Human Subjects, 21 C.F.R (2014) 9. Protection of Human Subjects, 21 C.F.R (2014) 10. McDonagh, Marian, Sheree Miller, and Ellen Naden. Costs and Savings of Investigational Drug Services. American Journal of Health-System Pharmacy 57 (2000): American Journal of Health-System Pharmacy. American Society of Health-System Pharmacy. Web. 6 Oct < long>. 11. LaFleur, Joanne, Linda Tyler, and Rajiv Sharma. Economic Benefits of Investigational Drug Services at an Academic Institution. American Journal of Health-System Pharmacy 61 (2004): American Journal of Health-System Pharmacy. American Society of Health-System Pharmacy. Web. 6 Oct < content/61/1/27.full.pdf html>.

22 22 Fall 2014 Core Measures Surgical Care Improvement Project (SCIP) Quality-Based Reimbursement (QBR) Reach 100% Sylvia Daniels, BSN, RN, Manager, Regulatory Compliance & Outcomes In 1971, hospital rate regulation in Maryland was established by an act of the Maryland legislature. The law created the Health Services Cost Review Commission (HSCRC), an independent state agency with seven commissioners appointed by the Governor. Since 1977, the HSCRC has set rates for all payers, including Medicare and Medicaid, and has largely achieved the key policy objectives established by the Maryland legislature. In recent years, the HSCRC has devoted considerable resources toward the development and implementation of payment-related initiatives designed to promote the overall quality of care in Maryland hospitals. In July 2009, the HSCRC implemented payment adjustments to hospital rates for the QBR initiative. For this initiative, hospital reimbursement rates will vary depending on each hospital s achievement on specified quality-of-care measures. For the initial year, 19 Hospital Quality Alliance (HQA) process measures were used for heart attack, heart failure, pneumonia, and surgical infection prevention. For the period between October 2013 and September 2014, there are eight process measures on which the QBR is based, and that includes the SCIP measures as listed below: Surgical Care Improvement Project (SCIP) Prophylactic antibiotic selection Prophylactic antibiotics discontinued within 24 hours after surgery end time Surgery patients on beta blocker therapy prior to admission who received a beta blocker during the peri-operative period Surgery patients with recommended venous thromboembolism prophylaxis within 24 hours before surgery to 24 hours after surgery Urinary catheter removed on postoperative day one or postoperative day two In 2010, under the leadership of Patricia Turner, MD, the SCIP steering committee was established. This was a multi-disciplinary committee with the charge to improve the organization s performance on the SCIP core measures. In 2012, the steering committee was reorganized to reflect the following members: Nader Hanna, MD, FACS, FICS Professor of Surgery, Director of Clinical Operations for General & Oncologic Surgery Beatrice Afrangui, MD Medical Director, Prep Center; Asst. Professor, Anesthesiology James McGowan, DHA Vice President, Perioperative Services Ingrid Connerney, DrPH, MPH, RN, CPPS Senior Director, Quality and Safety Margie Stickles, MSN, MBA, RN, CCRN Director of Nursing, Perioperative Services Jo Ann Sikora, MS, CRNP Lead Cardiovascular Nurse Practitioner Rebecca Schroder, MS, RN Quality Coordinator, Perioperative Services Masio Heyward, MS, RN Senior Systems Analyst Marie Wells, MS, RN, CNOR Nurse Educator, Perioperative Services Josephine Brumit, DNP, RN Clinical Practice Coordinator, Quality and Safety Sylvia Daniels, BSN, RN Manager, Regulatory Compliance and Outcomes Since the inception of this committee, several interventions (as listed below and with many still in place) have been implemented to improve our performance. They are: Antibiotic choice guidelines in MetaVision; Indications for ordering antibiotics made mandatory and postop antibiotic alert implemented 11/20/2012 in PowerChart; Concurrent review of ATBX within 60 minutes; outlier cases are sent to anesthesiology lead physician, who follows up with appropriate anesthesiology staff to validate review findings and revise documentation if appropriate: implemented January 2013; continued on page 23.

23 news &views 23 Core Measures, continued from page 22. Concurrent review with real-time feedback to nurses and physicians to illicit appropriate documentation for: Antibiotics Beta blockers Foley catheter DVT prophylaxis Venous Thrombosis Embolism (VTE) order for orthopedic patients revised to allow the use of aspirin in low-risk patients undergoing hip and knee surgery; Monthly letters sent to division chiefs notifying them of outlier cases failing the SCIP criteria; Post-op procedure brief operative note revised to include documentation of core measure requirements (i.e., beta blocker, VTE prophylaxis, Foley catheter removal and post-op antibiotics discontinued); Foley alert in Powerchart; Implementation of urinary catheter removal protocol; and Addition of Foley catheter order and urinary catheter removal protocol to all power plans. The graph at right shows the result of these interventions over a two-year period. We are pleased to announce that in July 2014, the Medical Center achieved the threshold rate of 100% compliance on the SCIP core measures that are included in the QBR initiative. The members of the SCIP steering committee are to be commended for their dedication and facilitation of the continuous improvement in our core measure performance. However, this threshold could not have been achieved without the hard work and support of the physician and nursing staff. To continue this momentum and to provide the best quality care possible, all members of the health care team must continue to be vigilant and focus on the appropriate documentation of the care they provide their patients. UMMC Compliance SCIP Performance Would you like to have your article published in News&Views? Submitted articles should: Present clinical and professional nursing practice topics in inpatient, procedural and ambulatory areas that are evidence-based, innovative, and outcomes driven. Focus on divisional, departmental and/or organizational strategic goals. See page 2 for submission guidelines.

24 24 Fall 2014 Accuracy of Blood Glucose Monitoring in Surgical Patients with bmi >30 kg/m 2 A Pilot Study by UMMC Nursing Pat Woltz, PhD, RN, Director of Nursing Research Background: Patients with obesity frequently undergo glucose monitoring after surgery to assess glucose metabolism. These patients have physiological factors that can increase variation in glucose levels based on the testing method used. Physiological factors include surgical trauma and alterations in glucose metabolism, nutrient intake, hematocrit, hydration status, and peripheral perfusion. Prior studies report disagreement between point-of-care (POC) and central laboratory glucose values in unstable patients. Nurses at UMMC noted that evidence was lacking about the accuracy of POC glucometer results for obese patients in the acute care setting the morning after surgery. Thus, nurses on Weinberg 5 and Gudelsky 9E (SIMC) helped design and conduct a prospective observational study that was funded by the National Association of Bariatric Nurses. The aim was to determine the nature and extent of agreement between glucose values obtained from capillary blood using the Roche Accu- Chek glucometer system compared to those obtained from venous blood using central laboratory devices for adult postsurgical patients with BMI > 30 kg/m 2. Methods: Following internal review board approval and patient consent, two glucose samples were drawn within 15 minutes on the morning of postoperative day one from 59 patients. Point-of-care glucometer procedures were standardized and strictly maintained during the study to minimize tester variability. Paired glucose values were examined using Bland-Altman (BA) and Clarke Error Grid (CEG) analyses. Bland-Altman plot is a method of data plotting that helps analyze agreement between two different clinical assays or measurement techniques, where each provides some errors in their measure. 1 Clarke Error Grid analysis takes into account not only the difference between the systemgenerated and reference blood glucose values, but also the clinical significance of this difference. 2 Using CEG zones, a clinician is informed about the severity of an erroneous measure using the laboratory value as the gold standard reference. Glucose pairs in zones A and B represent accurate (within 20% of the reference) or acceptable glucose results. Data points in zone C may lead to unnecessary correction and a poor outcome. Data points in zone D indicate a dangerous failure to detect and treat hypoglycemia or hyperglycemia, and those in zone E would lead to a confusing treatment of hypoglycemia for hyperglycemia or vice versa. The more values in zones A and B, the more accurate the device in terms of clinical utility. respectively). Using BA analysis, all pairs were within 95% agreement, except three (5.6%) (Figure 1). The three outliers could not be explained by other patient factors measured in the study, which included age, gender, BMI, surgical procedure, and hematocrit. Clark Error Grid analysis found that 45 (77.6%) and 13 (22.4%) patients fell into zones A and B, respectively (Figure 2). There were no patients in zones C, D or E. Discussion: Prior research shows that accuracy of POC glucose monitoring in the hospital setting varies by patient characteristics, patient condition, glucometer, and tester skill. This pilot study found that POC glucose monitoring appears safe in acute care, postsurgical patients with BMI > 30 kg/m 2. Methods had good agreement and, by CEG analysis, clinical accuracy of POC testing was acceptable. However, there were no hypoglycemic values in this study; thus, POC accuracy in the setting of hypoglycemia is unknown from this study. Additional research with a larger sample and a control group may provide insight into the factors that affect POC glucose testing in this population. Notably, since this study was completed, UMMC has Bland-Altman Plot B land-altman Plot continued on page 25. Findings: Blood glucose values across both methods ranged from 81 to 361 mg/dl in the study sample (N = 58). Capillary blood values by glucometer were, on average, 15 mg/dl higher than venous blood values obtained from the laboratory (149, SD 44.5 versus 134, SD 44.5 mg/dl, Figure 1 Mean of CB and VB (CB+VB/2)

25 news &views 25 Blood Glucose Monitoring, continued from page 24. Exemplary Professional Practice is Second Nature at UMMC Stephen Lewis, RN, Adult Emergency Department (AED) Figure 2: Clark Error Grid adopted a new and more accurate POC device, the Roche Accu-Chek Inform II system. To the best of our knowledge, the new device has not been similarly tested. Evaluating individual trends and current patient status is paramount for ensuring safety with bedside glucose monitoring. Nurses expert in providing care for specific patient populations need to question their practice and engage in inquiry to generate evidence for best practices. The study team (Kristin Seidl, PhD, RN (PI); Taibat Alao, BSN, RN; Anthony Aroh, BSN, RN; Patricia Bulacan, BSN, RN, CCRN; Priya Nair, MS, CBN, CMSRN; Vijaya Ramakrishnan, MS, CMSRN, CBN; Barbara Saia, MS, RN; and Pat Woltz, PhD, RN) would like to acknowledge the nursing staff on both units, particularly night shift, who were instrumental in data collection. References 1. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999; 8(2): Krouwer J, Cembrowski GS. A review of standards and statistics used to describe blood glucose monitor performance. J Diabetes Sci Technol. 2010; 4(1): SATURDAY, OCTOBER 25 TH As an AED nurse working in a fast-paced environment, it is often a challenge when we are transferring a patient to one of our inpatient units. We need to move quickly but be thorough in our initial triage so that patients are stabilized enough to transition them safely to the next level of care. I understand that some of our patients aren t always delivered to the receiving units in the best of shape. We work very hard to optimize the patient s status to the greatest extent possible during the short amount of time they are with us; however, we know there is more work to be done when they arrive on the inpatient unit. I strongly believe that we do a great job of prioritizing airway, breathing and circulation, which is the ultimate purpose of an emergency department. Giving verbal report and transferring monitored patients to inpatient units can be very smooth or uneven depending on how well the sending and receiving units work together to handle the transfer of care. Last Saturday, I transferred a patient to the medical intermediate care (MIMC) unit on North 10W and had a fantastic experience. The nurse that I spoke with was professional, concise, and cheerful in report. She asked very pertinent questions while being objective and thorough. After report, I transported the patient to the unit and was met with a warm welcome. The unit secretary waved and said hello with a big smile on her face. When I arrived at the room, several nurses, a patient care technician, and respiratory therapist were ready to help with the transfer from stretcher to bed. Everyone was friendly, professional, and hardworking. The whole team worked seamlessly to place the patient on the monitor, get important updates to his plan of care, and convey a sincere sense of caring for his well-being. I was so refreshed by the whole process that I couldn t stop smiling on my walk back to the AED. If anyone asks what I think of the MIMC, I will tell them it is a unit that delivers amazing patient care while demonstrating the inspiring power of teamwork!

26 26 Fall 2014 Lisa Rowen s Rounds, continued from page 5. Lisa Johnson, BSN, RN RN Coordinator, Oncology I took a lot of tips home about how to improve workflow and teamwork. But, my favorite part of the conference were the friendships that I made with the other nurses. I didn t know anyone before coming, but felt a connection immediately. Representing UMMC at Magnet made me really feel like part of this team. Kevin Marshall, BSN, RN CN II, Cardiac During the busy two and a half days I was able to attend six concurrent sessions, the poster session, as well as the award winners general sessions and evening events. One particularly compelling poster I encountered was presented by a nurse from Missouri. This poster detailed the role nurses play in contributing to hospital-acquired anemia, how it is associated with morbidity and mortality, and the interventions her unit put in place to reduce its impact. Barbara Bosah, BSN, RN SCN I, Surgical Intermediate Care & Progressive Care Units For the first time, I truly understood what it meant to be a Magnet hospital. I felt the pride as I truly understood what Magnet stood for and its affiliation. Fatemeh Jorshari, MSN, RN SCN I, Surgical Intermediate Care & Surgical Progressive Care This was my first time attending a nursing conference of such magnitude, and I must say it was a thrilling and rewarding experience. From the minute we departed gathered for the opening ceremony, attended numerous sessions, celebrated when our hospital name was announced, dined with our fellow nurses, managers, and our CNO to the minute we arrived back in Baltimore was a bundle of joyful and unforgettable experiences for me. The numerous topics and posters presented sparked ideas in many of us for future process improvement and research studies. I plan to share our experience and learning with our entire staff in hopes of leading the way for engaging all staff in the hard work it takes to sustain such an honorary status as a Magnet hospital. Shawn Hendricks, MS, RN, Ed-BC Nurse Manager, Medical Acute and Medical Telemetry The conference was an experience every nurse should encounter at least once. All of the sessions had great topics to choose from and were packed! However, I must say, UMMC is much more prepared and equipped with EBP, PI, and research than we think because 90% of the sessions that I attended were things we were already doing or have done in the past. So, we are truly on the move in the right direction! Robbin Witkowski, BSN, RN CN II, Surgical Intermediate Care Kim Sadtler, MSN, RN, PMHCNS-BC Nurse Manager, Child Psychiatry & Children s Day Hospital, and Adult Psychiatric Emergency Services Coming from a science background prior to becoming a nurse, it reminded me that not only are nurses caregivers and healers, but scientists as well. Listening to some of the speakers really started the gears turning for some potential innovations to bring back to UMMC. They truly prove that nurses pave the road to the future of health care practice and leadership. Finally, the conference allowed me to take a refreshing step back and see nursing from a bird s-eye view, realizing that though everything always comes back to the bedside, our profession extends so much further beyond it. The clinical nurse leader (CNL) is the first new masters-prepared nursing role in 35 years. It was designed to function at a microsystems level as a generalist nurse leader. The take-away message from the session on this leadership role was that development of a CNL council could be added to a shared governance model to increase leadership in process improvement initiatives across divisions. The authors in another session used transformational leadership qualities and complexity theory to address patient safety and nurse work environmental concerns over time, by implementing different interventions of leadership development for nurse managers. Next steps are to look at the relationship between the staff and nurse manager as a variable, including removing barriers, providing resources for nurses to do their job, and open communication. At another session, Data Transparency Drives Accountability and Improvement, the take-away was: UMMC could benefit from unit-specific data with all metrics in one centralized electronic location, so that front-line staff can access and understand the outcomes, benchmark, or target where improvements need to be made. Moreover, grades would be posted to compare against other units.

27 news &views 27 Journal Club Changes in Prevalence of Prescription Opioid Abuse after Introduction of an Abuse-Deterrent Opioid Formulation 1 Stacey Trotman, MSN, RN, CMSRN, and Kathryn Mello, RN, CMSRN Opioid sales in the United States are increasing substantially 2 and prescription opioid abuse is a growing public health problem. The number of opioid-related deaths now surpasses that of deaths due to motor vehicle accidents. 3 The U.S. Office of National Drug Control Policy put forth a national strategy aimed at addressing the epidemic rise in prescription drug abuse, which included the development of abusedeterrent formulations (ADFs). 4 The authors reviewed the report from a large natural experiment 1, which occurred on August 9, 2010 when the U.S. prescription drug market began supplying an ADF of oxycodone hydrochloride controlled-release (CR) tablets. This report examined patterns of opioid abuse before and after oxycodone ADF was introduced. The study used a large proprietary data source of the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO ) 5 to collect reliable and valid individual-level data via selfadministered, structured interview, along with product-specific data on the use and abuse of prescription medications over the past 30 days. Temporal trends (quarterly prevalence), pre/post changes in abuse following the ADF release, and changes in individual subgroup abuse patterns (oral only, snorting only, injection only) were evaluated. Researchers examined the abuse of 1) prescription opioids as a class; 2) immediate-release and extended-release opioids separately; and 3) other specific prescription opioid compounds and drugs of abuse (heroin, cocaine, amphetamine). Analysis used generalized estimating equations (GEE) models to evaluate the total study sample and then adjust for regional variation. Over 230,000 individuals ages 18 years and older at 437 facilities in 33 states were conveniently sampled and enrolled between January 2008 and December The sample was 65% male with a mean age of 32 years. Race/ethnicity was 54% white, 20% hispanic, and 19% black. United States geographical distribution was 41% west, 39% south, 15% midwest, and 4% northeast. The study found abuse among prescription opioids as a class and extended-release opioids. Abuse of opioids prior to the implementation of the ADF was increasing, but post implementation showed a sharp decrease in the prevalence of overall oxycodone CR abuse. Pre-post findings also suggests an increase in abuse of other opioid compounds through snorting and injecting, which are possibly being used as an alternative to the new drug formulation. Researchers concluded that while the study showed a decrease in the abuse of the new formulation of controlled-release oxycodone, this had little impact on the broader scope of overall rates of abuse of prescription opioids. Researchers further submit that the true impact of ADFs will not be identified until all opioid analgesics are developed in ADFs. Drug abusers appeared to quickly adapt to the introduction of the ADF to the market, suggesting that changes in formulation may cause shifts to increased abuse of other illegal drugs. Discussion Care providers must balance access to and prescribing of potentially addictive opioids with minimizing abuse and diversion of these drugs. Particularly for patients with chronic pain, controlledrelease opioid medications may provide a safer approach at the public health level to pain management. Increasing prescription opioid abuse challenges health care providers to place greater emphasis on substance abuse resources while being cautious of bias and documentation that labels patients as drug-seeking. More education may be needed for better understanding of the differences between opioid tolerance, dependence, and addiction. The group discussed other strategies for pain management, which include integrative medicine approaches, use of the C.A.R.E. TM channel and patient education about setting realistic pain management expectations, and assuring adequate pain management during periods of patient transitions. References 1. Cassidy TA, DasMahapatra P, Black RA, Weiman MS, Butler SF. Changes in prevalence of prescription opioid abuse after introduction of an abusedeterrent opioid formulation. Pain Medicine 2014; 15: Baldwin G. Public Health Grand Rounds: Prescription Drug Overdoses: An American Epidemic Available at: 3. Warner M, Chen LH, Makuc DM, Anderson RN, Minino AM. Drug poisoning deaths in the United States, Available at: gov/nchs/data/databriefs/db81.htm. 4. Office of National Drug Control Policy. Epidemic: Responding to America s prescription drug abuse crisis P.10. Available at: sites/default/files/ondcp/policy-and-research/rxabuse_plan.pdf. 5. Butler SF, Cassidy TA, Chilcoat H, et al. Abuse rates and routes of administration of reformulated extended-release oxycodone: Initial findings from a sentinel surveillance sample of individuals assessed for substance abuse treatment. J Pain 2013; 14(4):351-8.

28 22 South Greene Street Baltimore, Maryland Clinical Practice Update 1. Intake Screening for Novel Viruses: Ebola Update UMMC has partnered with the state and public health officials to create a very thorough and well- coordinated Ebola response plan. The most important parts of the strategy are identification, isolation, and notification as recommended by the Centers for Disease Control and Prevention (CDC). New patients are screened at all points of entry for international travel to any of the high- risk areas and are immediately isolated. 2. The next question appears: If patient answers YES Have you traveled within the last 21 days to, or had close contact with, someone who is sick who has traveled to: WEST AFRICA (Guinea, Liberia, Sierra Leone), CHINA ARABIAN PENNINSULA (Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, United Arab Emirates (UAE), Yemen) - - or ANY OTHER COUNTRY WITH AN OUTBREAK OF AN INFECTION? 3. The following notice appears: Again, If If patient answers YES Please initiate airborne, contact and droplet isolation immediately! Please advise the patient s provider of a possible novel infection case and notify Infection Control via pager Next steps: If the patient is suspected to have Ebola, additional questions are then asked to clarify the location and reason for travel, symptoms patient is experiencing and, if indicated, testing for Ebola is initiated. UMMC EBOLA PROGRAM FACTS UMMC has established a protected area that can be converted to house high- risk patients that contains custom features to protect staff and other patients from the spread of disease. o When converted to care for these patients, the area will have a small lab to avoid the need for specimens to travel to the hospital lab. Ebola testing is performed at the state health department and takes approx. 6 hours for results. The virus is generally transmitted when patients are at their sickest (viral load is high) and they have symptoms of fever and vomiting or diarrhea. A Dedicated Care Team (DCT) for suspected and/or confirmed patients with Ebola Virus Disease has been established and continues to grow. The team is comprised of physicians, nurse practitioners, respiratory therapists, rehabilitative therapists, and others who have expressed a desire to care for identified patients. Staff members from specialty areas such as pediatrics and labor and delivery will supplement the teams if their specialized knowledge is needed. Ebola is fairly easy to kill on surfaces with standard hospital disinfectants Dispatch is our cleaner of choice. For additional Information, please see