Documentation Training for Blood Product Administration At Hospital Corporation of America (HCA)

Documentation Training for Blood Product Administration At Hospital Corporation of America (HCA) Project 1: Design Document Sheeba Datta University of Texas Brownsville EDTC 6323 Multimedia/Hypermedia Summer 2013

Documentation Training for Blood Product Administration: Hospital Corporation of America (HCA) Instructional Goal Upon successful completion of this instructional module, HCA nursing staff will be able to demonstrate accurate documentation of Blood Transfusion Administration in Meditech system including; 1) completing transfusion verification forms, 2) transfusion procedure, 3) holding and resuming transfusion, 4) Documenting transfusion reaction. Performance Objectives 1. Using the simulated electronic documentation system -MEDITECH (CN), the clinicians will document blood transfusion administration (B) accurately and without assistance. (CR) 2. Once the blood is issued in MEDITECH(CN), the clinician will navigate to the TRANSFUSION screen and begin entering transfusion details (B) after verifying the patient data. (CR) 3. When patient condition warrants (CN), the clinician will navigate to the HOLD button and enter holding off transfusion process (B) along with the accurate time and reason. (CR) 1

4. Once the patient s status permits (CN), the clinician will use the RESUME button to restart the transfusion (B) along with accurate time and reason. (CR) 5. Within 4 hours since transfusion begin-time (CN), the clinician will click on the END button to complete the transfusion (B) along with accurate time and volume. (CR) Learner Analysis Pre-requisite skills: Pre-requirements for this instructional module include basic MEDITECH navigation skills and the user is a licensed registered nurse at HCA. Learners will be expected to navigate to various familiar MEDITECH modules for review of additional patient data and to retrieve accurate values. The registered nurses are already competent in documenting MEDITECH screens for Plan of Care, Order Entry and Process Intervention, which will be called into the Transfusion documentation module. Prior knowledge of instructional topic: The nursing staff is clinically competent in administering blood products and currently the documentation is performed in paper format. The essential data for blood administration as required by the regulatory policy remains the same in the electronic format also. Attitude toward content and delivery system: All the existing nurses have been performing computer documentation and LMS-based learning at HCA, providing a computer-based training is appropriate for these learners. Nurses are able to access HealthStream (LMS) from any Internet connection and complete the training. 2

Learner Motivation: The nurse in hospital units does not necessarily utilize certain vital documentation skills learned at the time of classroom training, right away or as frequently as routine procedures. One such special procedure is administering Blood Transfusion and accurate documenting it. The nurse has to document blood transfusion only when the patient is about to receive blood, which is not very frequent in all the patient units. This results in a performance gap, which in turn leads to inaccurate documentation and can potentially compromise patient safety. Nurses and management understand this issue very well and if instruction can be delivered with more flexibility and accessibility, these nurses will be more motivated to attend the training and effectively learn from it at their own convenience. Learner educational background and ability: Educational backgrounds of the nursing staff range from Associate degree in Nursing to Masters Degree in Nursing with board certification. All the nurses are computer literate and are already using the LMS for learning. Learners' preferences and learning styles: Nurses prefer hands-on practice while learning clinical skills. Hence the current practice for documentation skill training is through classroom training. All HCA nurses have been completing knowledge based courses and regulatory courses via HealthStream and they are familiar with navigation through HealthStream. An asynchronous course with simulated Meditech test environment, requiring their active participation is new to these nurses. Well-defined, unambiguous instructions will be provided on course navigation and about expected learning outcome 3

Attitude toward management: Among the clinical fraternity itself, the mandatory training administered, as a once a year session to validate competency is not perceived as the best mode of training. That practice is undergoing changes to include more courses offering all through the year and make it more accessible and flexible. Management s decision to make more courses online and provide access from anywhere is getting more acceptance from the nursing field, especially the night shift staff. Group characteristics: The pilot audience for this instructional unit will be 50 sampled nurses from 25 hospitals belonging to 5 HCA markets. This sample will consist of 10 male nurses and 40 female nurses, ages ranging from 23 65. The sampled nurses nursing job experience ranges from 1-40 years, making it a versatile group. Design/development risk: Among the nurses, attitude towards computer-based learning varies; generally younger nurses seemed to be more comfortable with computer based learning and older nurses needed more reassurance about this mode of instruction s effectiveness and ease of use. As a risk, the older nurses might resist the mode of training, until they get confidence in the self-paced courses. My recommendation is to develop super-user nurses to overcome this challenge. Context Analysis HCA s nursing staff is geographically distributed in 20 states across the country and the United Kingdom. Since all the existing nurses have been performing computer documentation and LMS-based learning at HCA, providing a computer-based training is appropriate for these learners. Nurses are able to access HealthStream (LMS) from any Internet connection and complete the training. Every hospital has computer labs where they can access this training and 4

also on any computer on the patient unit. The learner will be compensated for 30 minutes of work-time, at their basic pay, regardless of the actual time they utilize to complete the course. Learners can access the hospital intranet version of the course from any computer within hospital. Users will be instructed to launch the course via the web through high-speed Internet connection and they will require Adobe Flash Player to display the course. They will also need to play the audio narration to successfully complete the course. The learners will be able to pause the training and resume later as needed in HealthStream. The completed instructional module will be implemented and assigned through HCA s learning Management System (LMS) HealthStream. The course will be assigned by HealthStream administrators to clinical nurses with an established due date of completion prior to the MEDITECH upgrade. This format of delivery will address the compliance and course completion record maintenance, accomplished through the LMS itself. In this version of the course, the learner will be able to advance to the next module only after completing the previous section in the sequential events of instruction. Another format of the course delivery would be to publish the course in HCA s intranet site, facilitated through Microsoft SharePoint. In this format, the course would be more flexible by which the nurse would be able to access the course without logging into the LMS and also will be able to navigate to any section of the course without restrictions or mandatory pre-requisite sections. This will furnish as a reference format for the users, and be accessible anytime, within the HCA network. There will not be data collection on users' access to this course format. The following will be the available course delivery modes: 5

1. Demonstration Videos with narration of the new MEDITECH module BCTA Blood Transfusion Administration. This will be a passive instructional mode to provide an overview of the upgraded module. These demo videos will be available in the classrooms and at nurses units. 2. PowerPoint slide show with screenshots of the new BCTA module. The slideshow will be comparing the current practice of blood administration and the soon to implemented new technology to administer blood products. 3. Posters Workshops will be held to provide introduction to the new devices such as scanners and blood product labels, nurse will be oriented to the actual devices. Posters will be posted in the units with pictures of scanners and labels and emphasis on the scanning the blood products. 4. Intranet based interactive training The course will be accessible in reference format, at any time, on any HCA net work computer for increased flexibility 5. Pocket guide - with summarized BCTA steps as quick reference 6. LMS delivery - The course will be published and assigned to the nurses though HealthStream (LMS). HealthStream can be accessed not only within HCA network, but also from external WEB. 7. Headsets - Arrangements will be done materials department to make headsets available in sanitary way, in order to be utilized for attending the instructional module in any HCA classroom. 6

Assessment of Learning Outcomes This instructional module will prepare the clinicians at HCA for accurate blood transfusion documentation. The comprehensive performance objectives are outlined in the following Performance Objectives Chart, including assessments. Performance Objectives Chart The learners are expected to complete the performance objectives in an interactive simulated environment within 45 minutes and without assistance. CN = Condition, B = Behavior, CR = Criteria Instructional Goal Instructional Goal with Performance Context Goal: HCA nursing staff will demonstrate competency to accurately document Blood Transfusion Administration in MEDITECH including: 1) completing transfusion verification forms, 2) transfusion procedure, 3) holding and resuming transfusion, 4) transfusion reaction. Using the simulated electronic documentation system - MEDITECH (CN), the clinicians will document blood transfusion administration (B) accurately and without assistance. (CR) Assessment The instructional module will consist of a simulation of the MEDITECH screen with questions to test their navigational skills and documentation accuracy. This allows the learners to apply their newly acquired knowledge from the guided practice session and thus demonstrate their competency. Steps in Instructional Goal 1. Clinician will open Transfusion MEDITECH module and begin blood transfusion procedure Performance Objectives Once the blood is issued in MEDITECH(CN), the clinician will navigate to the TRANSFUSION screen and begin entering transfusion details (B) after verifying the patient data (CR) Questions In the simulation, navigate to the TRANSFUSION screen and verify forms 7

CN = Condition, B = Behavior, CR = Criteria Steps in Performance Objectives Instructional Goal 2. Clinician will perform When patient condition documentation steps in order warrants (CN), the clinician to HOLD blood transfusion will navigate to the HOLD button and enter holding off transfusion process (B) along with the accurate time and 3. Clinician will demonstrate how to use the RESUME function to restart the transfusion after placing the HOLD 4. Clinician will document transfusion reaction 5. Clinician will perform the steps to END the transfusion Save and file documentation reason. (CR) Once the patient s status permits (CN), the clinician will use the RESUME button to restart the transfusion (B) along with accurate time and reason (CR) If patient develops transfusion reaction (CN), the clinician will identify the REACTION button and document the reaction (B) along with accurate time and action taken (CR) Within 4 hours since transfusion begin-time (CN), the clinician will click on the END button to complete the transfusion (B) along with accurate time and volume (CR) Once the blood transfusion is completed, the clinician will click on the familiar save and file button Questions In the simulation, choose a reason code in the system for holding the transfusion. In the simulation, select a condition in which the RESUME function can be utilized without doctor s order. In the simulation, identify the actions to be taken in the event of a transfusion reaction In the simulation, click on the field for entering the blood volume and document 250ml of packed cells. 8

Instructional Unit Evaluation Rubric The flowing rubric will be used to evaluate this instructional unit, BLOOD TRANSFUSION: DOCUMENTATION TRAINING: Criteria Target Description Points Score Navigational Skills Correctly navigating to the relevant sections without errors 15 Verification of forms Identifies accurate patient data entries 15 Accuracy Documentation reflects accuracy and clarity 25 Documentation of Documents correct documentation in all fields 15 time field at all levels Determine patient s condition based on criteria Evaluates patient status during transfusion and documents all findings 25 Save and file Each instance of documentation is filed on time 5 promptly Overall Evaluation 100 Instructional Strategy Behaviorist principles will be applied predominantly in this instructional module. The learner will acquire new knowledge through observation and then strengthen that knowledge by performing in a simulated environment through guided practice. In this instructional module the main goal will be divided into sub goals (tasks) and they will be broken into instructional events 9

with demonstration, guided practice, with corrective feedback, independent practice and assessments. 1. Pre-Instructional Activities Prior to attending this instructional module, the learner will be presented with required prerequisites, which include: 1. Learner holds an RN license 2. HealthStream (LMS) account and familiarity in navigation within HealthStream 3. Completion of MEDITECH fundamentals course in HealthStream (LMS) 4. Completion of HCA Intranet & Atlas Navigation course in HealthStream Completion of this training will be mandatory for any registered nurse who will be performing Blood transfusion administration at any HCA hospital. Blood product administration remains one of the riskiest procedures performed by nurses in the hospital, as it involves frequent antigenantibody reactions resulting in serious patient harm and even fatality. Accurate documentation of every step is of vital importance to avoid patient harm and legal implications to the nurse and hospital. MEDITECH provides the electronic medium for documentation and the steps involved are complex requiring critical thinking on the part of the nurse, while documenting. Nurses are trained and competent in the physical procedure of blood administration but documentation can differ from hospital to hospital. Hence, this documentation training has to be mandatory for all the nurses; new graduates to very experienced professional nurses. This course will also act as a reference material for any nurse who needs additional resources on the documentation topic. 10

2.Content Presentation The module will be chunked into five sections to facilitate learning and prevent information overloading. Chunking will also ensure learner grasps each task before proceeding to the next task. Instruction for each section will be provided in a clear and precise manner. The five tasks include: 1. From the main MEDITECH Nursing Menu, nurse will select the patient and navigate to the TRANSFUSION screen and document data for blood administration. In the simulation, click on the TRANSFUSION button and follow prompts. 2. When patient condition warrants for holding off the transfusion, nurse will click on the HOLD button. Document the time and reason(s) for holding the transfusion. In the simulation, click on the HOLD button and follow prompts. 3. When patient status permits for resuming the transfusion, nurse will click on the RESUME button after documenting the reasons for resuming transfusion along with time. In the simulation, click on the RESUME button and follow prompts. 4. In the event of transfusion reaction, nurse will click on the REACTION button and document the observed and stated reactions with time. In the simulation, click on the REACTION button and follow prompts. 5. Complete the transfusion administration documentation by clicking on the END button, which has to be performed within 4 hours of, begin time. In the simulation, click on the END button and follow prompts. The training will be presented as a narrated, guided practice allowing student to pause and practice as many times as they want. This will be followed by independent practice with 11

immediate corrective feedback. The training is of 45 minutes length and learners familiarity with MEDITECH menu navigation will help them complete the training in the required time. 3.Learner Participation The synchronized screen narration will be recorded in true human voice and represented by a professionally dressed nurse as a screen agent. This will provide the learners with a virtual instructor experience and identify with the scenarios and procedures as they do in their practice. Learner will be allowed to pause and resume training as required. The previously completed sections will be accessible through the main menu all the screens. The virtual training through simulated environment will provide the learner a familiar documentation environment, without having to practice in a live environment where there is a zero tolerance for risk of errors and above all, that could be unethical too in a healthcare set-up. Feedback The learner receives corrective feedback for their assessment in real-time as it is a web-based activity. If the answer chosen is wrong, learner will be prompted to try again. The assessments will include feedback structure with explanation why an answer is wrong. Learner will be providing feedback on the course thorough the Course Survey activity, included in HealthStream, as part of the training. 12

4.Follow-through Activities Upon completion of the training, learners will be provided with the following materials: 1. A printed Certificate of Completion for Blood Transfusion Documentation Training. This certificate is required for the supervised competency evaluation by the preceptor in the live MEDITECH system 2. A pocket guide with main steps involved in blood transfusion documentation, in checklist format 3. A test on blood transfusion documentation skills will be administered through HealthStream for all nurses, every six months, in order to assess the competency. This is conducted to make sure that all nurses maintain the skills, even when the actual blood administration procedures in some units such as Newborn Nursery might not be as frequent as in other units such as ICU. 13

Storyboard Goal Statement: HCA nursing staff will demonstrate competency to accurately document Blood Transfusion Administration in MEDITECH including: 1) completing transfusion verification forms, 2) transfusion procedure, 3) holding and resuming transfusion, 4) transfusion reaction. 14

References: HCA Blood Transfusion Policies Retrieved from HCA Atlas (internal site) HCA MEDITECH Manual Retrieved from HCA Atlas (Internal site) Dickerson, S.S & Feitshans, L.A. (2003) Internet users becoming immersed in the virtual world: implications for nurses. Computers in Nursing. 21 (6), (pp.300-308). Gulati, S. (2006) Application of New Technologies. In Glen, S. & Moule, P. e-learning in Nursing. (pp.20-23). Basingstoke: Palgrave Macmillan 15