Magnet Recognition Program® Request for Additional Documentation
Homestead Hospital
Homestead, FL
MGN20140102
NK4EO Innovation in nursing is supported and encouraged.
NK4EOb: Provide two examples, with supporting evidence, of an improvement that resulted from an innovation in nursing. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
The expansion of Homestead ED services for the sexual assault victim example did not describe, with supporting evidence, an improvement that resulted from an innovation in nursing.
Provide an example, with supporting evidence, of an improvement that resulted from an innovation in nursing.
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A new example is presented below.
NAME OF INITIATIVE
The “Nitro” Project
BACKGROUND/PROBLEM
In the United States, angina (or chest pain) affects 10.2 million people with pre-existing coronary artery disease (CAD) (Sansone, 2010). CAD is the leading cause of death and chest pain is its primary manifestation (Gallagher, 2010). Sublingual nitroglycerin (SLNTG), in combination with morphine and oxygen, is the drug most commonly prescribed for chest pain (Gallagher, 2010).
At Homestead Hospital, clinical nurses use established protocols to manage patients with chest pain. The protocol is based on guidelines and recommendations stipulated by the American Heart association. Oxygen is first administered, followed by SLNTG 0.4 mg tabs every 5 minutes, up to 3 times. In severe cases of chest pain, nitroglycerin intravenous drip may be necessary.
In order to return perfusion to ischemic areas and prevent further damage to cardiovascular muscle, it is essential that SLNTG be available to be administered as quickly as possible. In 2014, nurses on MS5 noticed that there had been several incidents when an emergent chest pain situation had arisen and SLNTG was unavailable in the Pyxis (medication dispensing system). Although, these incidents did not result in patient harm, there was a potential for harm and negative outcomes. The problem was brought to the MS5 Unit Practice Council (UPC) by Clinical Nurse Miguel Uribe, RN, wherein a project team was assembled to develop a potential solution.
To validate their observation, the UPC deployed a survey to 30 clinical nurses on MS5, a total of 16 responded. Of those, 62.5% indicated that they have gone to the Pyxis and SLNTG had not been available; the remaining 37.5% stated it had been available. Although the largest response category on the survey indicated that the estimated elapsed time between code call and administration of SLNTG was 2 minutes (18.75% of respondents), data from chest pain codes on the elapsed time from code call to the first SLNTG tablet administration had averaged 6.45 minutes.
After some discussion, the UPC uncovered one possible underlying reason for the occasional unavailability of SLNTG: a lack of standardized process for its removal from the Pyxis. For example, rather than removing the necessary number of tablets, some nurses would usually remove the entire bottle of SLNTG, take the bottle to the room during the code or event, and then forget to return the bottle to the Pyxis, leaving the bin empty. Thus, when SLNTG was needed in the future, it would be unavailable in the Pyxis. This results in the nurses having to search other Pyxis stations within the department for the medication or having to obtain it from the pharmacy.
The other reason for the occasional unavailability of SLNTG was attributed to instances in which the bottles that had been removed were not replaced by pharmacy. This was because the pharmacy system had recorded that only a few tablets had been removed to treat the patient (rather than the entire bottle that was actually removed) and therefore would not alert the pharmacy staff that a replacement was needed. Pharmacy also did not conduct regularly scheduled SLNTG inventories to ascertain that the number of pills actually left in the Pyxis matched the report.
The UPC determined that in addition to potential delays in care, the missing SLNTG bottles also signaled potential lost revenue for the unit and organization. Pharmacy ordered SLNTG in bundles of 4 bottles at a cost of $44.17 per bundle (the bundle cost has subsequently increased to $45.83 per bundle). Each bottle of SLNTG containing 25 tablets costs $11.07 or 0.44₵ per tablet. The average cost associated with lost SLNTG from December 2013 to January 2015 was $18.22/month.
Literature Review
Clinical Nurse and UPC Co-Chair Rosa Filomeno, RN, conducted literature search in CINAHL using key terms such as nitroglycerin administration, process, availability, dispensing, and usage. The search did not return any studies describing how SLNTG tabs were actually dispensed from the Pyxis or other medication tracking and dispensing systems. The literature did contain several studies on the appropriate use of SLNTG and its mechanism of action (Sansone and Murphy, 2010).
GOAL STATEMENT(S)
To reduce the cost associated with lost SLNTG on MS5.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
The standard practice at Homestead Hospital required the scanning of patient medications at the bedside immediately prior to administration, as a safety measure to avoid administration errors. Thus, in the case of SLNTG, standard Pyxis systems required the removal of the entire SLNTG bottle in order to scan the barcode at the patient’s bedside in compliance with medication administration safety protocols.
During the MS5 UPC meeting on November 2013, members brainstormed about possible solutions to the problem of missing SLNTG. One solution suggested by Clinical Nurse Uribe was that during emergent situations, nurses would not take the entire bottle of SLNTG. Instead, they would remove the maximum potential dose per patient (i.e. 3 tablets) and place the tablets in a cup that would be bar-coded with information corresponding to the patient’s room. The nurse would then administer 1 tablet, every 5 minutes (maximum of 3 tablets), as per protocol. This idea would allow the nurse to scan and administer the medication, while leaving the bottle in the bin for the next nurse to use. It would also reduce waste or loss of SLNTG because the number of tablets removed would correspond to how the medication was tracked in the pharmacy system.
The MS5 UPC determined that this would be a worthwhile solution, which would require much coordination and collaboration between MS5 nurses and pharmacy personnel. In December 2013, Filomeno, together with MS5 UPC Chair and Clinical Nurse Steve Trush, RN, met with Patient Care Manager Maria Carillo, RN. They presented their idea for the project and obtained her support and approval. One week later, they discussed the plan with the Medical-Surgical Service Director Hector Aleman, RN, who was excited about the proposed solution and offered his support and encouragement to move forward with it.
In January 2014, the UPC presented the MS5 staff with the problem and asked if they would be willing to pilot a change in the process used to access SLNTG from the Pyxis. An overwhelming majority of the staff responded positively to participation. In February 2014, Filomeno presented the project to the Homestead Hospital Evidence-based Practice and Research Council (EBPRC). The EBPRC recommended that the UPC, in conjunction with the pharmacy, consult with Performance Improvement (PI) Manager Larissa Vega, RN in order to approach this project using the principles of TRIM (Teams, Refocus, Imagine & Measure). TRIM is a performance improvement program that utilizes value stream mapping and A3 process tools.
In April 2014, an interprofessional team, including MS5 Clinical Nurses Trush, Filomeno, Uribe, and Jones; Clinical Pharmacy Supervisor Winifred Pardo, PharmD; Pharmacy System Specialist Belkys Borgen; and MS5 Clinical Nurse Educator Aracely Olvera, RN, met to discuss the problem and begin the TRIM. Vega facilitated the TRIM process, during which, the team described the standard process of dispensing SLNTG; identified storm clouds (opportunity areas); and defined the ideal state.
Exhibit NK4EOea: Standard Process of Dispensing SLNTG
It took the group 4 months to go through the full TRIM exercise. At the end, the team was able to delineate specific changes to the process as follows:
1. Rather than removing the entire bottle during a chest pain event, the nurse would remove 3 tablets and place them in a pre bar-coded paper cup to the patient’s room. The bottle would be left in the Pyxis with the remaining tablets.
2. If any of the tablets in the paper cup remained unused during a chest pain event, the patient’s account would be credited at the end of the event.
During the next several months, pharmacy worked on developing the barcodes to be used on the paper cups. Beginning in February 2015, Olvera educated the staff on the new process with the assistance of several UPC members. They provided the education during staff meetings and shift huddles. They also educated the Pharmacy staff on the new process and on how to supply the bar-coded cups for SLNTG in the Pyxis bins. MS5 Patient Care Supervisors (PCS) on the unit also initiated weekly inventories of SLNTG at this time. Thereafter, MS5 went live with the new process in April 2015.
Novel Set of Nursing Behaviors and Routines
Rather than create a new process to accommodate the needs of existing technology, this project required the adjustment of technology to accommodate the new process. Specifically, the standard process required the removal of the entire bottle containing SLNTG during a chest pain event because of the need to scan the barcode on the medication bottle at the patient’s bedside immediately prior to administration. The innovation in nursing involved using pre-bar coded medication administration cups with the nurse removing only the maximum dose of SLNTG (3 tablets) and placing them into the cup. This eliminated the need for clinical nurses to carry bottles of SLNTG to the bedside.
Exhibit NK4EOfa: Innovative Process of Dispensing SLNTG
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Miguel Uribe, RN, CMSRN |
Clinical Nurse |
MS5 |
Came up with the innovative idea; UPC Member |
Rosa Filomeno, MSN, RN, CMSRN |
Clinical Nurse |
MS5 |
Spearheaded the project; UPC Co-chair |
Steve Trush, RN, CMSRN |
Clinical Nurse |
MS5 |
UPC Chair |
Joyce Jones, BSN RN, CMSRN |
Clinical Nurse |
MS5 |
UPC Member |
Aracely Olvera, BSN, RN, CMSRN |
Clinical Nurse Educator |
MS5 |
Assisted in staff education |
Larissa Vega, BSN, RN, CMSRN, CPHQ |
Manager |
Performance Improvement |
Facilitated TRIM process |
Maria Carrillo, BSN, RN, CMSRN |
Patient Care Manager |
MS5 |
Facilitated roll-out |
Maria Ojeda, ARNP, MSN, MPH, DNP/PhD-c, NP-C |
Nurse Scientist |
Nursing and Health Sciences Research |
Assisted with data management |
Hector Aleman, MSN, RN, CNML |
Director |
Medical Surgical Services |
Provided administrative support |
Winifred Pardo, PharmD |
Clinical Pharmacy Supervisor |
Pharmacy |
Served as pharmacy consultant |
Belkys Borgen |
Pharmacy System Specialist |
Pharmacy |
Served as Pyxis consultant and provided Pyxis reports |
OUTCOME(S)
The average cost associated with lost SLNTG from December 2013 – January 2015 was $18.22 per month. With staff education; weekly inventory of SLNTG; and roll-out of the new process, the average monthly cost of lost SLNTG was immediately reduced to $0 in February 2015 and remained at $0 through July 2015. Filomeno presented the project to the Nurse Governance Council in June 2015. Because of their outcomes, NGC supported a hospital-wide implementation of the project. The team is in the process of collecting pre-data for the house-wide roll-out.
Exhibit NK4EOga: Cost of Lost Sublingual Nitroglycerin in MS5
Analysis: Above graph demonstrates that the MS5 UPC achieved their goal of reducing cost associated with lost SLNTG as evidenced by $0 lost for 3 consecutive months post-intervention.
References
Ferreira, J., C., B., and Mochly-Rosen, D., (2012). Nitroglycerin use in patients with myocardial infarcts. Circulation Journal : official journal of the Japanese Circulation Society, EISSN 1347-4820, 2012, Volume 76, Issue 1, p. 15.
Henrikson, C. A., Howell, E. E., Bush, D. E., Miles, J. S., & al, e. (2003). Chest pain relief by nitroglycerin does not predict active coronary artery disease. Annals of Internal Medicine, 139(12), 979-86. Retrieved from http://search.proquest.com/docview/222190051?accountid=458.
Sansone,J., and Murphy, R,. E., (2010). Chronic stable angina: disease progression or status quo? Clinician Reviews, 20(3), 18-2. Retrieved from http://search.proquest.com/docview/195787921?accountid=458.
Savill, P. (2010). Chest pain of recent onset requires prompt diagnosis. Practitioner, 254(1730), 19-22, 2. Retrieved from http://search.proquest.com/docview/1009906504?accountid=458.
Steele, R., McNaughton, T., McConahy, M., & Lam, J. (2006). ADVANCES: Chest pain in emergency department patients: If the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM : Journal of the Canadian Association of Emergency Physicians, 8(3), 164-9. Retrieved from http://search.proquest.com/docview/195787921?accountid=458.
Thanavaro, J. (2015). Chest pain, fever, and an abnormal electrocardiogram. The Journal for Nurse Practitioners, 11(1), 146-148. doi:http://dx.doi.org/10.1016/j.nurpra.2014.10.022.
Zane, R. D. (2005). Chest pain relief after nitroglycerin: Aid to diagnosis? Journal Watch.Emergency Medicine, doi:http://dx.doi.org/10.1056/EM200509140000007.
Summary of Attachments/Hyperlinks/Evidences
Exhibit NK4EOea: Standard Process of Dispensing SLNTG
Exhibit NK4EOfa: Innovative Process of Dispensing SLNTG
Exhibit NK4EOga: Cost of Lost Sublingual Nitroglycerin in MS5
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