Nursing BiennialReport 2013-2014

As a Magnet ® organization the

opportunity to recognize our

professional practice is an honor as it

demonstrates our continued journey

and commitment to service excellence.

I am pleased to share the 2013-2014

Nursing Annual Report for University

Hospital, which showcases the great

work and contributions made by nurses

throughout our hospital.

This report features select

accomplishments that reflect the

on-going commitment to adapt to

Magnet changes as well as innovation

brought about with health care reform.

Our shared governance structure

transitioned to a new professional practice model and re-designed the various

councils to better serve the needs of nurses and support more engagement of

front line nurses. As you read through this report, you will discover evidence

of how University nurses have embraced a deeper focus on patient and family

centered care as well as utilizing innovation in practice and technology to

foster the safe delivery of care both. The infusion of evidence-base research

has become the basis to guide nursing practice at University Hospital so that

the environment patient care is delivered support quality outcomes.

It is an honor that University Hospital is consistently recognized as having the

Best Nurses in the CSRA by the National Research Corporation. Indeed our

nursing staff takes their profession, passion and commitment to care for others

seriously which is evident as they embody nursing excellence in all that they do.

It is an honor and privilege to serve such an amazing team!

Sincerely,

Lynda Watts, RN, MSM, BSN, NEA-BC Vice President of Patient Care Services and Chief Nursing Officer

Welcome

Excellence IN PRACTICE

In 2013, the UH nursing staff completed the

transition to a new professional practice model.

The previous practice model was complex,

informed by an eclectic set of theoretical system

theories and models with nursing application.

After careful deliberation, the nursing SG

representatives created the new model consistent

with our philosophy and values, as well as

our previous systems approach. Depicted in

the figure below, the Excellence in PRACTICE

model is framed by University’s commitments

of Quality, Service, Teamwork, Community,

Affordability, and Professionalism and the values

of ongoing professional development; high-

quality, patient-centered care; and collaborative

teamwork. Excellence is an umbrella concept

that encompasses high-quality care, safety, and

the interdisciplinary nature of nursing with each

of the following constructs identified:

P – Patient-Centered: The patient/family/

community needs guide the focus of our care.

We respect the individuality of our patients and

advocate for quality care sensitive to their needs.

R – Respectful Relationships: The contributions

of all members of the healthcare team are to

be recognized and respected and it is nursing’s

ethical responsibility to treat others with respect

and promote environments conducive to high

quality healthcare.

A – Accountability and Autonomy: Nurses

have the authority and responsibility to practice

in accordance with established patient care

standards. This accountability is to self, patients,

members of the healthcare team, organization,

and external agencies. Nurses at University have

the autonomy to influence patient care standards

at the unit and division level and to make

choices regarding how to provide care to meet

the individual needs of patients within the care

delivery system.

C – Caring and Healing Environment: We are

committed to creating an environment to foster

patient-centered care based on the unique

physical, psychological, spiritual, and emotional

needs of each patient.

T – Technological Advancements: We are

committed to using innovative technology to

support and promote highest quality of care.

I – Interdisciplinary Collaboration: Interdisciplinary collaboration is critical to

ensuring comprehensive care within our system

and involves respecting the skills and knowledge

of each team members to optimize outcomes.

C – Continued Professional Development: We are committed to promoting ongoing

professional development to support evidence-

based care and nursing engagement.

E – Evidence-Based Decisions: Evidence-based

practice is foundational to the care provided and

nurses are expected to incorporate the best-

available information into the creation of practice

standards and daily patient care.

Patient-Family Centered Care is fundamental to

our PRACTICE professional practice model. Our

nurses do not consider family members as “visitors”

but as integral to our patients. We want families

to find University a place to help impart ease and

comfort while their loved ones receive care. The

Jernigan Cancer Center Family Waiting Room

renovation is a shining example of our emphasis

on patient-family centered care.

Looking at the Jernigan Cancer Center Family

waiting room now, it’s difficult to imagine the

former area where families were confined to

waiting, praying, resting and communicating with

extended family and friends in a small outdated

space with no windows and only one Caring

Bridge computer station. Thanks to the support

of the Volunteer Board of University Hospital

and proceeds from the Jernigan Memorial Golf

Tournament, families are now able to gather,

support one another, and retreat in an inviting and

comfortable space.

The room is beautiful, with bright natural lighting,

and includes a kitchenette, play area for children,

private bathroom, and two computer stations with

access to Caring Bridge. It helps to make the

uphill battle that the entire family fights when a

love one is diagnosed with cancer more bearable

and is reflective of the Foundation’s mission to care

for our community and families facing a battle.

A special thank you to the Jernigan Family

for allowing proceeds from the 27th Annual

Jernigan Golf Tournament to be allocated for

this renovation, the Jernigan Golf Tournament

Sponsors, the Volunteer Board, the Hospital Board,

the Foundation Board, the Projects Department, 

and to the families and staff of the Jernigan

Cancer Center for their input.

Patient & Family

Centered:

Jernigan CanCer Center Family Waiting room

University’s W.G. Watson M.D. Women’s

Center has offered Mother’s Choice

“service” for well over two decades—doing

whatever we could to honor our patients

and families “special” requests. As our

namesake, Dr. Watson, said … “Service and

Kind Words.” Every one of us deserves

to celebrate/experience events in our life

in our very own way. And a birth is one

of the most memorable times in our lives!

The Golden Hour is one example of this

patient and family focus.

The Golden Hour is that first hour after

birth which has been proven to be

critical for bonding and establishing

successful breastfeeding. In 2013,

our Women’s Center nurses fully and

formally implemented The Gold Hour

to promote skin-to-skin contact with

minimal interruption as our standard of

care. Historically, babies were whisked

away from mother moments after birth

to be measured, weighed, inspected, and

warmed. However, as long as the mother

and baby are healthy there is no reason

to move the baby to the nursery and

disrupt this first hour. We find most of our

patients will immediately want to bond

with their new baby and most will want

to breastfeed; that’s the standard and we

know it’s the best. We are still sensitive to

those mothers who may not want or be

able to do so, hence MOTHER’S CHOICE.

Breastfeeding has come “full circle” and is

now even an international quality imperative,

a Healthy People 2020 goal, and one that

The Joint Commission has also introduced

as a Core Measure. We are in the initial

stages nationally of public reporting on

lactation! Moms make choices on things

like this, things they believe are (or are not)

important to them and it’s our role in nursing

to educate and support them as much as

we safely can! If parents have requests that

are outside the “norm,” we look into options,

check the literature, find out what others

do, and strive to provide the best of care.

We look to see how we can help!

Evidence-based care is a cornerstone of

our nursing practice. And we definitely

want and need to stay the front-runners,

delivering the highest standard of care — the

very best practice! Nurses have the distinct

honor of helping people; we are patient and

family advocates by profession! Being a

Magnet hospital means you have the very

best of the best of nurses; and those nurses

are focused on delivering the highest quality

of care and compassion. What better time

to start than the Golden Hour?

MOTHER’S CHOICE — for patient/family focus

aiDet respeCtFul relationships

RespectfulRelationships

Respectful relationships are a fundamental

component of our PRACTICE model. Our

nurses strive to embed the highest standards of

customer service in our patient-centered care. In

2013, University embraced the use of the AIDET

communication model to enhance respectful and

courteous communications between all individuals

within the facility.

What is AIDET? AIDET is a mnemonic reminding us

of the components of respectful communication.

It all starts with Acknowledging another person’s

presence with a smile or a word, then Introducing

ourselves and our purpose in a respectful way. We

share the Duration of what we will be discussing or

doing, so that they understand how long it will take,

then Explain what we need to do and what will be

involved. Finally, as the interaction ends, we Thank

the person to let them know we are appreciative

that they placed themselves in our care. We also

take this opportunity to invite any further questions

or needs.

We have diligently worked to “hardwire” the

AIDET process into our nursing staff, as well as

all others at University. In early 2013, 100 percent

of staff completed training in this communication

method. We are seeing related improvements in

communications, levels of patient involvement,

clinical outcomes, and patient satisfaction. Using

AIDET has guided consistent and empathetic

communication with patients and families, helping

us to always demonstrate our concern and

appreciation.

The Emergency Department (ED) is

the first con tact many of our patients

have with University Hospital and our

ED nursing staff strives to op timize

patient experiences. In 2013, the UH

ED nurses implemented a unit-based

charter to design and implement

processes to improve the triage

process for patients.

The new process ensures that a

specially trained triage nurse greets

and assesses patients upon ar rival to

registration, determining the acuity

using a 5-point scale. This early

assessment and triage allows patients

to be more quickly directed to the

appropriate area of the ED, facilitating

timely and effective care.

The ED nurse educator, Denise Simon,

BSN, CEN became a Triage First

trainer so that she could educate ED

nursing staff on implementation of

this evidence-based set of resources.

In the future, classes will be offered

monthly, as the goal is for all nursing

staff to complete the training.

In 2014, to further benefit our ED

patients, we added ER Express,

an online program allowing pa-

tients to identify when the next ED

“appointment” is available, as well as

appointment options in our the UH

Prompt Care settings.

Streamlining the Emergency

Room Experience

As part of promoting respectful

relationships, our nursing staff recognizes

the importance of professional appearance

to instill confidence by patients and our

colleagues. In 2013, University’s leadership

considered the transition to color-coded

professional attire for staff in several

disciplines, including nursing. Nationally,

other facilities have adopted color-coded

uniforms to enhance patients’ ability to

differentiate between the roles of staff

as a means of enhancing safety and

customer service. As the literature on this

subject was largely anecdotal, our nurses

conducted a brief patient survey to identify

our patients’ needs prior to transitioning to

the new color-coded dress policy.

In August 2013, after obtaining IRB

approval, the nurse researcher surveyed

patients on eight units. Patients verbalized

some difficulty in knowing staff roles and

overwhelmingly indicated that color-coded

uniforms should help in this regards. They

were complimentary of existing efforts to

identify staff, such as name tags, consistent

self-introductions, and “white boards” but

also described reliance on their ability to

read staff members’ name-tags and recall

the introductions. Thus, the move to color-

coded professional attire was made in

September to enhance patient safety and

satisfaction. University staff nurses now

wear royal blue uniforms throughout the

organization and other staff members dress

according to their discipline’s dress code.

This move to color-coded professional

attire was adopted as an evidence-

based project by nursing with follow-up

patient surveys planned. We feel that it

is important for our patients to be able

to recognize their nurses and to dress

in a way that presents a professional

appearance consistent with our licensure.

neW uniForm poliCy

University’s nursing Shared Governance (SG)

program is designed to provide a structure for

nursing staff involvement, accountability, and

promotion of quality care, ultimately improving

patient outcomes. In 2012, the nursing staff

decided it was time to revise the existing SG

structure, in place almost ten years. The new

streamlined model was implemented in late

2012 and early 2013; it includes a more simplified

division-level council structure and a more

consistent unite-level structure.

Our SG structure moves decision-making closer to

the point-of-care, with Unit Leadership Councils

(ULC) known as “triads.” Triads are comprised

of two unit nurse representatives (one from

each shift) and the nurse manager; triads work

closely with unit staff to identify and address

opportunities for improvements related to patient

care and unit processes. Unit-level SG projects are

accomplished through unit-level committees and

work groups. Triad members also represent their

units on the division-level SG councils.

The division-level SG now consists of three

councils and a number of committees and

workgroups. The councils are Transformational

Leadership Council (TLC), Exemplary Professional

Practice Council (EPPC), and Structural

Empowerment Council (SEC).

EPPC: The EPPC oversees evidence-based nursing

practice, practice innovation, and research and

includes standing committees such as the Practice

Committee.

SEC: The SEC oversees professional engagement,

professional development, teaching and role

development, community involvement, and

nursing recognition, with relevant committees

appointed.

TLC: The TLC is responsible for the overall nursing

strategic plan and consistency of nursing care

throughout the organization.

Accountability& Autonomy

ShAREd GovERNANCE

Shared Governance Touchback Sessions

unit BaseD triaD aCComplishments

Cardiac Cath Lab

Improvements resulting in decreased

radiation expo sure for staff

Cardiovascular PACU

Evaluation and selection of new cardiac

pillow, associated with increased comfort

and zero dehiscence rate

6NS and Cv3

Pilot of “pass with care” initiative resulting

in decreased pa tient falls

7NS

Implementation of pharm tech role

to enhance patient education while

supporting nurses with decreased

medication administration time

8NS

Enhanced hourly rounding with

emphasis on identification of patients at

heightened risk for falls and to ensure that

appropriate safety measures in place

10NS

Established quarterly unit newsletter to

promote communication and collegiality

among staff

10W

Enhanced patient education

processes, ensuring resources readily

available for staff on needed topics

GYN

Testing use of new patient transfer

equipment to increase patient com-

fort moving from stretcher to bed while

promoting safe patient handling

oB

Pyxis reorganization enhancing availability

of needed products while in creasing

savings

SCN

Increasing awareness of and participation

in continuing education op portunities

Ed

Instituted Triage First improving the

registration and triage process for ED

patients

Surgical Services

Creating one combined resources for

policies, proce dures, and infection control

guidance for use by all surgical areas

Each month, unit representatives to the EPPC and SEC present their unit’s charters,

describing unit-based initiatives, goals, progress, and outcomes. Examples of recent unit

specific accomplishments include:

Lynda Watts, our CNO, is a great proponent

of nursing autonomy and recognizes that our

nurses are the best resources when it comes to

identifying nursing needs. In mid-2014, Lynda

hosted a series of “Power Hours”—brainstorming

sessions with groups of nurses representing

diverse units invited to explore what our

strengths and opportunities for improvement.

During the sessions, issues such as nursing

retention and recruitment, staffing and support

roles, nursing satisfaction, patient flow and

placement, and equipment availability were

discussed. A number of initiatives emerged from

these conversations.

For instance, in summer 2014, a number of plans

were implemented to enhance nursing retention.

At the same time, nursing and human resources

launched the “80 in 80” plan aimed to hire 80 new

nurses within 80 days. The goal was exceeded,

resulting in many new nurses joining our staff.

To optimize recruitment, we instituted Magnet

Mondays. Every Monday from 9 a.m. until 11 a.m.,

a recruiter is available in the hospital lobby

to speak with nurses interested in careers at

University.

PowerHours

7ns pilot:addition of pharmacy technician role

In December 2013, the 7NS nursing staff

participated in a project de signed to

measure and review the proportion of

their time spent in var ious direct and

indirect patient care, activities, with

an aim to consider staffing options

to increase their availability to focus

on professional nursing tasks. They

found that they spent more time in

medication administration activities than

reported by other facilities. In 2014, the

interdisciplinary team reviewed options

and elected to conduct a pilot adding

a pharmacy technician role on the

nursing unit to support their medication

administration activities. A pharmacy

technician would be able assist the

nursing staff with pulling medications

for the Pyxis, obtaining the medication

history, contact patients’ pharmacies or

providers to obtain accurate medication

reconciliations, etc. This project was

successful. Based on the evidence from

7NS, the project is being replicated on

8NS in late 2014.

Lynda Watts, RN, MSM, BSN, NEA-BCVice President of Patient Care Services and Chief Nursing Officer

In 2013, the Shared Governance representatives

reviewed, updated, and approved an ongoing

strategic plan. The Professional nursing staff

within University Hospital has a robust strategic

and operating plan consistent with that of the

organizational plan. The first component is the

strategic plan, which includes the cornerstone

elements of the mission; vision, commitments and

long term strategic goals framed around five pillars:

SERVICE, QUALITY, AFFORDABILITY, PEOPLE, AND

GROWTH. The second component is the annual

operating plan, which consists of the organizational

priorities, the teams accountable for translating the

priorities and tactics into action, and the performance

measurement criteria. Both components of the plan

are influenced each year by the data generated from

numerous sources including, but not limited to, staff’s

perceptions of the professional practice environment

survey, patient satisfaction surveys, and the work of

the Shared Governance Councils.

LoNG-TERM FoCUS:

The Strategic and Annual Operating Plan is the

basis upon which the Vice President of Patient Care

Services and the Division is evaluated. Within the

strategic framework are the University Health Care

Hospital mission, vision and commitment; definition

of Nursing, goals, philosophy and objectives.

nursing strategiC plan

people

Nursing at University will attract,

retain, and develop excellence in

professional nursing dedicated to

evidence based practice and high

quality patient-family centered care.

groWth

Nursing at University Hospital

will engage staff in activities that

promote expanding services for our

community.

aFForDaBility

Nursing at University Hospital will

be engaged and supported by a

professional practice culture and

climate which supports cost effective

care delivery. Through structural

empowerment nursing will design and

contribute to the development of the

future cost containment strategies.

Quality

Nurses at University Hospital will

place quality-caring relationships

at the center of our practice

resulting in safe compassionate care

demonstrated by excellence in patient

outcomes.

The following depicts the primary goals

under the categories of People, Growth,

Affordability, and Quality.

In March of 2013, University Hospital implemented

a safe patient handling program to prevent injuries

and ensure safety for patients and staff. The

development of our safe patient handling program

began in October 2011 with an equipment

expo to display transfer and mobility devices

by ArjoHuntleigh, Inc. Staff were encouraged

to “test drive” the equipment and submit

recommendations for purchase. Equipment was

purchased based on these recommendations in

2012. For a period over 6 months, employees

were trained on the safe mechanics of lifting

and use of the transfer and mobility equipment.

To ensure mastery of necessary skills, each

employee was required to return-demonstrate

the use of any equipment/devices purchased

for his/her unit. Practice standards and

computerized documentation have been revised

to accommodate the changes in clinical practice.

While hospitals have traditionally relied heavily

on body mechanics training, there is considerable

evidence-based research that indicates this

training alone is not effective in preventing strain/

sprain injuries associated with patient lifting.

The United States Bureau of Statistics, based

on information from the Department of Labor

Occupational Safety and Health Administration

(OSHA) indicates nurses and patient care

assistants are consistently within the top ten of all

occupations at risk for physical injuries. Two years

prior to implementation of the program, greater

than 15% of all employee injuries were the result of

patient care related strains/sprains. The incidence

of patient-care related strain/sprain injuries was

cut in half following introduction of the equipment.

Caring &Healing

Environment

SAFE PATiENT hANdLiNG PRoGRAM

Sacral Preventative dressing ForCaring and healing Environment

As an organization consistently seeking

ways to promote a caring and healing

environment, University Hospital has a long

history of extremely low pressure ulcer

prevalence. However, the nursing staff

continually seeks opportunities to further

decrease, if not eliminate, ulcer formation

all together.

In mid 2013, after performing months

of testing showing consistent positive

outcomes, the nursing staff decided to

implement the use of a new foam sacral

preventative dressing. They then continued

to be engaged with the implementation

of this new dressing by aiding in the

development of policies, in services, and

modifications to the electronic health

record as well as the development of a

nurse driven protocol to address at risk

patient populations.

Once substantial education was completed,

the use of the new sacral dressing was

implemented house-wide for those patients

who met high-risk criteria. The use of this

dressing has now aided in a measurable

decrease in the development of new sacral

pressure ulcers, as evidenced by our 2013-

2014 Quarterly Preventative Studies.

Q4 2012

Q1 2013

Q2 2013

Q3 2013

Q4 2013*

Q1 2014

Q2 2014

Q3 2014

Q4 2014

Sacral Ulcers 3 4 3 0 0 0 0 0 0

3

4

3

0 0 0 0 0 0 -0.5

0.5

1.5

2.5

3.5

4.5

5.5

Number of Sacral Ulcers Q4 2012--Q4 2014

Technological Advancements

UH has consistently evaluated emerging technology for evidence that it would favorably contribute to the outcomes of our care. In 2013, in addition to the continued implementation of EPIC, our electronic health record (EHR), a number of other resources were tested and several implemented.

The EPIC electronic health record (EHR) is a key

component in improving patient safety, clinical quality

outcomes, service, and operational performance.

University nurses have historically been instrumental

in the design and implementation of our electronic

resources and EPIC was no exception. University

implemented the EPIC EHR in December 2012 and

early 2013. Throughout the planning phases and

ongoing evaluations, clinical nursing staff members

have been included in the decision-making processes

related to enhancing our documentation system to

not only meet regulatory guidelines, but to improve

efficiency in providing patient care. Engaging

nurses in throughout the process empowers them to

improve professional nursing practice. An example is

the development of Best Practice Advisories (BPAs)

which alert the nurse to required documentation

components, such as home medication review,

immunization screening, and heart failure education.

Optimization of the EHR is an ongoing process that

will assist in keeping ahead of inevitable changes in

health care, while maintaining excellence in nursing.

EPiC: TEChNoLoGY

LUCAS 2 TEChNoLoGY

In 2013, the emergency was very fortunate to obtain

the LUCAS 2 compression system, an example of

new technology enhancing clinical outcomes. The

LUCAS 2 system is designed to deliver uninterrupted

compressions at a consistent rate and depth, in

order to facilitate return of spontaneous circulation.

As any nurse knows, performing manual CPR is

difficult and tiring. However, high quality CPR is

vital in order to deliver oxygen to organs while

maintaining sufficient coronary perfusion. LUCAS

is portable, lightweight, and easy to use. It frees

up a nurse or other staff member who would

ACCUvEiNS hAvE ARRivEd ... FoR TEChNoLoGY

The AccuVein 400 is a vein illuminator that helps

nurses and other clinicians locate superficial veins up

to 10mm. It operates using infrared light to detect

veins beneath the skin, then projecting the position of

the veins on the skin surface directly above the veins.

During July and August, 2013, a clinical evaluation of

the device was conducted by clinical nurses. Based

on overwhelmingly positive reactions from both staff

and patients, 21 devices were purchased. All relevant

nurses were educated on the use and maintenance

of the device, including vein location techniques, in

October 2013, when the devices were made available

throughout the organization.

otherwise be performing chest compressions. Most

importantly, it leads to improved patient outcomes,

our final goal.

Nursing is represented as essential part of the many UH interdisciplinary teams. Our teams have successfully pursued and maintained quality resulting in a number of national certifications and/or recognitions, including heart failure, chest pain, stroke, total joints, breast health.

hEART FAiLURE iNTERdiSCiPLiNARY TEAM:The Heart Failure Interdisciplinary Team (HFIT) is nurse led collaboration whose goal is to provide the highest quality care to the patient. An interdisciplinary team offers their professional knowledge and experience to solve problems to improve patient outcomes. The HFIT consists of Physicians, Heart Failure Program Coordinator, Nurse Managers, Staff Nurses, TeleHealth Nurses, Pharmacists, Registered Dieticians, Case Management, and Performance Improvement. Fall 2013 University Hospital’s Advanced Heart Failure program was surveyed by The Joint Commission, who identified opportunities for the organization to improve care of the heart failure patient across the continuum. As Heart Failure Program Coordinator and Leader of the HFIT, Terri DeFusco, BSN, RN has spearheaded the following initiatives to achieve success with TJC identified opportunities for improvement:

n An easy self-assessment tool that would help any care giver to understand the patient’s perception of heart failure wellness. The stoplight tool provides a visual for signs of worsening HF and reminds patients to call their doctor for assistance rather than going to the emergency room. The stoplight tool is written at a fourth grade level to reach our demographic. Laminated copies of the stoplight tool are hanging in the patients rooms throughout the hospital as a visual reminder for the staff, patient and family.

n The New York Heart Association (NYHA) classification of functional capacity was chosen as the method to monitor patient’s progress throughout the continuum of care by our team. This scale was added to our EPIC admission navigator and care plan for the nursing staff

and physicians to assess the patient’s functional capacity. The change in functional capacity over time is visible to all care providers.

n Partner with the patient, to understand what goals they want to achieve considering their current condition. Focusing on the goals of the patient help us to identify their barriers and facilitate a partnership to make a difference in the transition of care to home or community. The goals and interventions are added to the care plan and discharge instructions which help the patient achieve their goals.

n Dr. A. Bleakley Chandler states “I have enjoyed our heart failure rounds over the last six months [starting in Oct. 2013]. I think it has improved the care of our patients. First, the nurses caring for these patients have gotten really good at understanding them from a heart failure point of view. They have learned the difference between systolic and diastolic heart failure and the appropriate medications. They have learned the importance of tracking their [the patient’s] weight as well as their functional class and short term and long term goals. We have also focused on advance directives. In addition, our team including Terri DeFusco and Jeff Langford, PhrmD., frequently pick up on patients who are not on appropriate medications, need to have a discussion about an AICD or who need a Cardiology consult. All in all our heart failure patients have directly benefited from our rounds.”

Through the direction of a nurse led interdisciplinary team by Terri DeFusco, BSN, RN the opportunities identified by TJC to strengthen the effectiveness of University Hospital’s Advanced Heart Failure Program have been implemented. Using feedback from frontline nursing staff and the intellectual capital of the team, the initiatives have made a tremendous difference in the ability of all disciplines to assess and clearly understand the patient’s perception of self and personal goals that result in improved

InterdisciplinaryCollaboration

The TAVR (transcatheter aortic valve replacement)

program is another example of a highly visible,

nurse-coordinated program. The TAVR program

was envisioned by Drs. Les Walters/Kraig Wangsnes

and Timothy Hunter during a conference in June

2011. This new technology that was previously only

available in Europe was soon to be available to

commercial sites in the United States pending the

outcome of the Partner Trial.

 

They discussed having a TAVR program at University

Hospital with the Administration.  The Administration/

Board approved the possibility of having a TAVR

program.  University Hospital first had to apply

to be considered a possible TAVR site and had to

meet very strict requirements set forth by the Food

and Drug Administration (FDA) and the Center

for Medicare Services (CMS) as well as with the

Edwards Lifesciences Company (the only TAVR

valve company at that time).  Once the requirements

for both the facility and the physicians were provided,

University received approval to start their program.

(Summer/June 2012). 

 

They had to hire a coordinator for the program and

establish a formal clinic to screen potential patients 

diagnosed with severe aortic stenosis as defined by

the American Cardiology College organization (ACC)

Severe Aortic Stenosis is defined as: A Jet velocity

> 4.0; Mean Gradient > 40 mmHg; Valve Area < 1.0

cm2/m2 or a valve index < 0.6.  In addition, to be

eligible for the TAVR procedure, the patients had to

be seen by 2 cardiothoracic surgeons and deemed

inoperable (not candidates for traditional open

surgical aortic valve replacement or SAVR).

 

By Sept 1, 2012 a coordinator was recruited (Susan

Wodarz, RN, BSN) and patients identified with severe

aortic stenosis were seen in a clinic space on the

Cardiovascular Care Center (CVCC) one Tuesday

per month.  An Average of 5 patients seen per month

were seen within the first few months.  In November

of 2012 the indication for patients considered High

Risk was approved by the FDA and CMS which

increased the new referral numbers to 10 plus

patients per Tuesday.

 

By December 2012, the need for additional clinic days

and more clinic space was evident. The Structural

Heart Clinic was formed and began seeing patients

in a shared area with the Weight Management Clinic

located on the first floor of the Heart and Vascular

Institute in January 2013. (Clinic days are now every

other Tuesday throughout the month.)

 

On February 5, 2013 the first TAVR procedure was

successfully performed in the hybrid OR. 

 

By the end of December 2013 we had screened close

to 100 patients identified with Severe Aortic Stenosis;

completed 25 successful TAVR cases; referred 12

patients for traditional SAVR and continued to follow

patients who are in need of TAVR but have not quite

met the criteria.

 

To date, our hospital has completed a total of 31

TAVR cases.  We have a 100% procedural success

rate (which means that 100% of our patients have a

successful implantation of their new valve and leave

the OR alive) A statistic that is shared by only a few

hospitals in our Region.

 

The TAVR program (Structural Heart Clinic) continues

to grow and flourish under the Collaborative Heart

Team made up of one RN and 8 Physicians (2

Interventional Cardiologists; 2 CT Surgeons;1 invasive

cardiologist; 1 cardiac anesthesiologist; 1 Radiologist)

and many supportive departments throughout the

hospital (CVCC; CVP diagnostics; Radiology/CT; Pre-

op testing; Surgery Care Center; Cath. lab staff; OR

staff; CVPACU staff; CV3 Staff)  

 

The high quality outcomes of the TAVR patients are

due to the entire team of health care professionals

(Physicians, Nurses, and Techs.) at University Hospital

doing what they all do best! 

taVr program:

Annually, our nursing staff recognizes those

among them who have taken the added step to

demonstrate excellence through achieving national

certification. In 2013 and 2014, we recognized

significant gains in the number of nurses with this

distinction — an increase of approximately

59 percent between 2012 and 2014.

Our efforts to promote certification amongst

our nursing staff include hosting certification

prep courses, peer-to-peer encouragement,

examination fee reimbursement, and an hourly

differential for certified nurses. In late 2013,

our certified nurses got a new resource to help

them maintain their credentials when University

subscribed to the EBSCO Nursing Reference

Center. Suddenly our nurses gained access to

hundreds of evidence-based continuing education

programs, in addition to the many other resources

incorporated in this resource. We anticipate that

having this resource available to our staff at point-

of-care and from their personal computers will

enhance their ability to earn the necessary CE to

support their maintenance of certification.

CERTiFiCATioN

Continuing Professional

Development

In December 2010, the landmark IOM Future

of Nursing report was released. One of the

recommendations made was to increase the

proportion of nurses at the baccalaureate or

higher level to 80 percent by the year 2020.

At University, we have made a commitment to

pursue the 80 percent by 2020 goal, focusing

on our staff nurses. A number of resources are

in place to support academic advancement by

our nurses, including tuition reimbursement,

scholarships, and organization partnerships with

academic nursing programs. In 2014, during a

major hiring initiative, we instituted a requirement

that newly hired non-BSN prepared nurses

commit to obtaining the degree within 4 years.

This move will enhance the success we have

already achieved. Between 2011 and mid-2014,

we increased the percentage of staff nurses with

baccalaureates from 50.1 to 58.4 percent -- an

increase of almost 17 percent in three years!

AcademicContinuing

ProfessionalDevelopment

Nursing retention is a major issue for

hospitals and providing an effective

transition from the academic setting

to the hospital setting is filled by both

excitement and apprehension for the

graduate nurse. In 2014, the ED

director sought opportunities to improve

the transition of graduate nurses into

the ED. The ED clinical educator,

Denise Simon, BSN, CEN developed

a 13-week Emergency Department

Fellowship Program for graduate nurses,

incorporating the Emergency Nurses

Association (ENA) online orientation

course which covers a broad scope of

practice to deliver quality urgent and

complex care for patients across the

lifespan as part of an orientation plan.

The Fellowship, launched April 2014,

consists of orientation time, clinical

lectures and the ENA course. In 2014, 17

graduate nurses successfully completed

the Fellowship, which was offered three

times.

Ed FELLoWShiP LAUNChEd

Evidence-based decision-making is employed

throughout our facility and the nursing staff. UH

has a number of resources in-place to support this,

including online resources readily-available, such

as the EBSCO nursing reference center and the

cadre of clinical nurse educators.

CvPACU BLood FiLTER—EvidENCE BASEd CARE

CVPACU staff nurses Sandee Daust and Robin Slagle

asked the question: Why do we double filter blood

when administering packed red blood cells (RBCs)?

While we had done this for at least 25 years, no one,

including our cardiothoracic surgeons, remembered

why it was originally ordered in that way. Sandee

and Robin implemented an evidence-based practice

project to examine the available evidence and

literature to determine whether double-filtering of

packed RBCs was necessary in open heart surgery

patients and considered a cost analysis of the Pall

filters used in CVPACU.

Finding no literature to support the practice of

double-filtering the blood, they took the question

to University’s Microbiology and Lab Manager,

who assured them that all blood administered at

University is leukocyte washed, negating the need

for double filtering. Further, it was determined that

there would be significant savings in eliminating the

un-necessary practice. The annualized cost savings

from eliminating the extra filter was $3,500 and there

would be further savings in nursing time. Thus, it was

a win-win for all when a new practice standard was

approved in 2013, eliminating this needless step.

This one project depicts the role of University Nurses

in promoting evidence-based practice and properly

using technological advancements, components of

our nursing practice model. The reliance on evidence

and cost-savings to the organization support the

Nursing and Organization strategic plans.

EARLY ELECTivE dELivERiES

Early elective deliveries (between 37 and 39

completed weeks of gestation) have increased

dramatically in the years 1990-2006 and the US

labor induction rate more than doubled during this

period, from 9.5 to 22.5 percent, while the cesarean

rate grew to a high of 32 percent. The increase is

rates is likely due to a number of factors, including:

incorrect patient belief that it is safe to deliver as

early as 36 weeks, culture in hospitals, and fee for

service payment models. A recent review of the

literature identified the negative consequences

possible for mother and babies. Women and babies

where the mother is induced at the 37th-38th week

have significantly higher risk of having cesarean

section, postpartum complications, neonatal

mortality and morbidity, and baby’s placement in

the NICU. Both maternal and neonatal lengths of

stay also increase with either elective induction or

elective cesarean section.

An interdisciplinary committee involving physicians,

clinical educators, clinical nurse director, nurse

managers, and later unit clerks, assistant nurse

managers and nursing staff. They set a goal in L&D to

decrease EEDs to zero, or less than 5 percent which is

one of the core measures as a shift in culture towards

evidence-based care.

The committee established an algorithm of when and

how to receive inductions in the OR as well as L&D for

the unit clerks. A Hard Stop was initiated September

25, 2013. We have a significant decrease. The rate

had decreased to 6.3 percent in December 2013 and

3.1 percent in December 2014.

Evidence Based

Decisions

1350 Walton WayAugusta, GA 30901

www.universityhealth.org