NK4EO Innovation in nursing is supported and encouraged.
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.
Example 1
NAME OF INITIATIVE
Implementation of Wireless I-Stat in the Emergency Department (ED)
BACKGROUND/PROBLEM
Chest pain is the second most common reason a patient visits the ED, accounting for approximately 6% of all adult patients presenting in the ED with chest pain as a chief complaint. Troponin is a biomarker that is essential for diagnosing myocardial infarction and for risk stratification of patients presenting to the ED with symptoms of Acute Coronary Syndrome (ACS). The Society of Cardiovascular Patient Care (SCPC) recommends a choice of 1 of 2 methods in performing troponin testing, namely Point-of-Care Testing (POCT) or laboratory testing. Homestead Hospital chose the Abbott iSTAT Analyzer POCT to achieve timely troponin turnaround time. SCPC Chest Pain Center accreditation guidelines also recommend a median turnaround time of 60 minutes. In 2012, SCPC required that 90% of the time, troponin collect-to-result turnaround time be at 60 minutes or less in order to meet their benchmark.
From April 2012 to August 2012, Homestead Hospital ED’s median door-to-troponin result turnaround time was 45 minutes. However, the median percentage for troponin collect-to-results turnaround time of 60 minutes or less was at 81%. This was lower than the desired benchmark of 90%. Chest Pain Center Coordinator and Patient Care Manager Joan Baker, RN engaged the ED Unit Practice Council (UPC), chaired by Clinical Nurse Eduardo Zarate, RN, to address this opportunity area. Subsequently, the UPC created an iSTAT Taskforce.
GOAL STATEMENT(S)
The UPC iSTAT Taskforce aimed to increase the percentage of troponin collect-to-result turnaround time of 60 minutes or less from 81% to 90% of the time. The measure used to demonstrate improvement was based on the SCPC standard of care and benchmark. Data was obtained from POCT database and analyzed on a regular basis using Chart Runner.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
The UPC iSTAT Taskforce first met in July 2012. During this initial brainstorming meeting, the team analyzed the existing process to determine steps that could be eliminated or added. They also collaborated with the Chest Pain Center (CPC) Committee, Registration, Cardiology and Laboratory departments in developing solutions to achieve the desired goal. In the ensuing meetings, The UPC iSTAT Taskforce explored new technology to address the issue. The team researched the literature on innovation in this area. After assessing several alternatives, the group selected a wireless iSTAT option with the Abbott Company. Unlike previous iSTAT technology, this wireless innovation enabled automatic population of results without the need of docking the machine to a workstation. The wireless technology decreased the dependence of the ED staff on laboratory services for their turn around times and availability of results and improved the staff’s experience in their ability to initiate treatment in a timely manner. The analyzers would be readily available to all end users within the department and would afford the nurses and ED technicians real time access to results, thereby facilitating prompt treatment of patients.
The UPC iSTAT Taskforce used the Plan-Do-Check-Act (PDCA) model as a guide in the project planning and implementation. They formulated a process improvement plan as follows:
- September 2012: Redesigned the workflow to automatically obtain POCT troponin after EKG completion using the iSTAT analyzer and ED technicians to assist in the collection process. (NK4EO 01 Redesigned Workflow Flowchart)
- September 2012: Requested ED Leadership to purchase wireless I-STAT analyzers
- January 2013: ED Director Sherine Craig, RN approved the purchase of 5 wireless iSTAT Analyzers
- February 2013: Installed wireless iSTAT analyzers
- March 2013: Re-educated EKG technicians, ED and Registration staff on identifying typical and atypical ACS patients
- March 2013: Educated all ED staff on wireless iSTAT analyzer
- May 2013: Started using wireless iSTAT in the ED
Baker, POCT Coordinator Anette Perry, Clinical Nurse Judy Bird, RN, Patient Care Supervisor Pang Xiong, RN, and Clinical Nurse Nancy Doctura, RN, who were members of the CPC Multidisciplinary Committee, tracked metrics weekly and disseminated findings at monthly ED staff meetings and to the providers. Baker evaluated outcomes of the new processes and sent out weekly KUDOS to “Troponin superstars”.
Exhibit NK4EOa: Wireless iSTAT Machine
PARTICIPANTS
The members of the UPC i-STAT Taskforce were
Name/Credentials |
Years Work Experience / Years Specialty Experience |
Title |
Department |
Role in the Team |
Joan Baker, MSN, RN, CCRN, CNRN, CCPC |
39 years / |
Chest Pain Center Coordinator |
ED |
Team Leader |
Eduardo Zarate, BSN, RN |
6 years/ |
Clinical Nurse; ED UPC Chair |
ED |
Member |
Judy Bird, MSN, RN |
6 years / |
Clinical Nurse; ED UPC Member |
ED |
Member |
Monica Roca, BSN, RN |
2.5 years/ |
Clinical Nurse; ED UPC Member |
ED |
Member |
Nancy Doctura, BSN, RN |
20 years / |
Clinical Nurse, ED UPC Member |
ED |
Member |
Pang Xiong, BSN, RN |
8 years/ |
ED Patient Care Supervisor |
ED |
Member |
Rusette Arends, BSN, RN, CPEN |
25 years / |
Clinical Nurse Educator |
ED |
Member; Educator |
Fernando Paz, EMT/ Paramedic |
10 years/ |
ED Technician/ ED UPC Member |
ED |
Member |
Annette Perry, BS, MLS |
42 years / |
POCT Coordinator |
Laboratory |
Member |
Jorge Mauricio |
16 years / |
Cardiology Supervisor |
Cardiology |
Member |
Diane Carrington |
20 years/ |
Registration Supervisor |
Admitting |
Member |
Candice Robinson |
8 year/s |
Lead Patient Financial Representative |
Admitting |
Member |
OUTCOME(S)
Re-engineering the workflow in the ED, training ED technicians to perform troponin POCT, and using wireless analyzers decreased troponin turnaround time. Additionally, the median door-to-troponin turnaround time decreased from 45 to 27 minutes after implementation of wireless iSTAT analyzers.
Exhibit NK4EOb: Percent of Troponin POCT Collect-to-Results in 60 Minutes or Less in the ED
Analysis: Above graph demonstrates that the ED UPC iSTAT Taskforce exceeded its goal of having 90% of troponin POCT collect-to-result at 60 minutes or less and sustained it for 16 consecutive months.
References
Hess EP, Wells GA, Jaffe A, Stiell IG, BMC Emergency Medicine, 2008; 8: 3. A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology. .
Loewenstein, Devin, Stake, Christine, Cichon, Mark, American Journal of
Emergency Medicine, 2013 Aug; 31 (8): 1236-9. Assessment of using fingerstick blood sample with iSTAT point-of-care device for cardiac troponin I assay. .
Koehler, Jeanniline, Flarity, Kathleen, Hertner, George, et al. Advanced
Emergency Nursing Journal, 2013 Jul-Sep; 35 (3): 270-7. Effect of Troponin I Point-of-Care Testing on Emergency Department Throughput Measures and Staff Satisfaction
Steinfelder-Visscher J, Teerenstra S, Gunnewiek JMT, Weerwind PW; Journal
of Extra-Corporeal Technology, 2008 Mar; 40 (1): 57-60. Evaluation of the iSTAT point-of-care analyzer in critically ill adult patients.
Takakuwa KM, Burek GA, Estepa AT, Shofer FS, Academic Emergency
Medicine, 2009 Oct, 16 (10): 921-7. A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction.
Summary of Attachments/Hyperlinks/Evidences
NK4EO 01 Redesigned Workflow Flowchart
Exhibit NK4EOa: Wireless iSTAT Machine
Exhibit NK4EOb: Percent of Troponin POCT Collect to Results in 60 Minutes or Less in the ED
Example 2
NAME OF INITIATIVE
MUJER: A Partnership to Provide an Innovative Service to the Community
BACKGROUND/PROBLEM
MUJER, Inc., (Mujeres, Unidas, en Justicia, Educacion, y Reforma; Men and Women United in Justice, Education and Reform), established in 1994, is a non-profit community-based organization that has helped the South Dade community with issues of domestic and sexual abuse. They were the first organization to address family violence issues among Latinos. MUJER has been certified as a rape crisis center by the Florida Council Against Sexual Violence and is a member of the Sexual Assault Response Team (SART). They respond to calls originating south of Kendall Drive to Florida City, including the City of Homestead, Florida. In the City of Homestead alone, there were 18 sexual assault cases reported in 2011, 30 in 2012 and 32 in 2013. MUJER also provides a spectrum of support services to the victim to assist with the recovery after the traumatic incident such as safety planning, counseling, relocation, legal representation, immigration services, emotional support and children’s groups.
In February 2014, Homestead City Commissioner Judy Waldman invited Homestead Hospital CEO Bill Duquette to a meeting. She also invited to this meeting representatives from MUJER, Homestead Police Department and other interested parties. MUJER SART Coordinator Anna Obregon communicated that they have received a grant to develop a SART for South Miami-Dade. She explained that sexual assault victims had to travel to Roxcy Bolton Center, located in Jackson Memorial Hospital (approximately 35 miles away) if they opted for forensic specimens to be collected, which was the first step in the justice process. She added that victims wanted to stay in the community they were familiar with and did not want to travel in the face of this traumatic circumstance. At the conclusion of the meeting, Duquette agreed to have Homestead Hospital as a forensic collection site for Deep South Miami-Dade. This would entail Homestead Hospital using county protocols and Sexual Assault Nurse Examiner (SANE) training for the ED nurses.
Thereafter, Duquette met with key hospital and nursing staff including, Chief Nursing Officer and Vice President Gail Gordon, RN, Assistant Vice President Ana Cabrera, RN, Emergency Department (ED) Director Sherine Craig, RN, and Performance Improvement/Case Management Director Jill White, RN. The nurse leaders became very excited about the opportunity. They felt that having ED nurses trained in SANE would provide a much needed service to the sexual assault victims of Deep South Dade. ED Patient Care Supervisor Silvia Hill, RN took the lead in this project and became the Homestead Hospital liaison.
GOAL STATEMENT(S)
The overarching goal for this project was to put in place a process for caring and timely treatment and referral of sexual assault victims in the community. Specifically, it aimed to see an increase in the number of sexual assault screenings in Homestead Hospital ED through its partnership with MUJER.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
In late March 2014, the South Dade SART Planning and Development Committee met. This was led by representatives from MUJER and attended by representatives from Homestead Hospital (Duquette, Gordon and Craig), Start Off Smart, Homestead Police Department, FIU Marketing, Florida Coalition Against Domestic Violence, Florida Council Against Sexual Violence, Banyan Street Community Center, and OneStop Legal Aid. During this meeting, the committee reviewed SART protocols, marketing of the rape hotline and collaboration with Florida Council against Sexual Violence (FCASV) to provide education resources and a 40-hour training class for the ED nurses to become SANE nurses. The committee met again in April 2014 and ironed out more details about the training, the grant and the protocol needed to become a forensic collection site.
In June 2014, Hill, together with MUJER representatives, traveled to Tallahassee, Florida for a SART meeting and training where she learned about the importance of first responders and the impact they have on the patient and the investigation. She also gained insight that coordination of a victim-centered community response was key in successfully caring for these patients. Following the trip, she shared the information learned with her department and with Duquette, Gordon and Craig. With the assistance of Craig, she then went about assembling a team of female and male ED nurses from day and night shifts to take the upcoming 40-hour SANE course. Nineteen ED nurses volunteered. In the same month, Homestead Hospital contracted with FCASV to provide training to 20 ED nurses. Homestead Hospital assumed training costs amounting to approximately $7,000.
In September 2014, 17 ED nurses took the initial 40-hour SANE course conducted onsite by Terri Augspurger, MSN, RN, CFN, SANE-A, SANE-P, AFN-B/C, DABFN, DABFE. This training was the first step in the process as there were further competencies that these nurses would need to get signed off such as speculum examinations for visualization; clinical forensic examination; case observations; case completions; police rides; and tour of the crime laboratory that process sexual assault kits. This project would be a huge undertaking by the organization and required commitment from the nurses.
In the same month, just several days following the training, the ED received a received a high profile sexual assault case. The SANE training helped the nurses in caring for the patient as well as they did. It was also a learning opportunity that enabled the ED team to identify gaps in their process. With the help of Obregon from MUJER, Hill spearheaded the development of an algorithm for the ED staff to follow. The algorithm provided details on the victim’s point of entry into the facility; the patient care from arrival to discharge; assigning a SANE-trained nurse; guidelines for admission, discharge or transfer; obtaining an advocate, if the victim wanted one; and the referral process to MUJER. In October 1st, 2014, Hill conducted mandatory in-services for the ED staff. She also attended staff meetings to inform the ancillary departments about the initiative and the new process.
Innovation in Nursing
The partnership between Homestead Hospital and MUJER is an innovation in service delivery utilizing a novel set of working relationships with community partners. The organization’s connection with MUJER has paved the way for better collaboration with other community advocacy agencies and local law enforcement to provide sexual assault intervention and a seamless referral process. Any hospital could become a forensic collection site. The innovation here is leveraging on community partherships that has provided administrative efficiency in serving the community to improve the treatment/health needs and patient experience. As mentioned above, the key to treating these victims is a community response. The SANE-trained ED nurses are in a unique position to provide not only direct patient care but also coordinated care to this vulnerable patient group.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Silvia Hill, RN |
Patient Care Supervisor |
ED |
Program Lead |
Debbie Carides, BSN, RN |
Clinical Nurse |
ED |
Lead On call Nurse and Evidence Collector |
Maria Gonzalez, RN |
Patient Care Supervisor |
ED |
Researched on available grants to support the initiative |
Regine St. Victor, BSN, RN |
Patient Care Supervisor |
ED |
Coordinated education activities |
Sandra Brown, RN |
Clinical Nurse |
ED |
Worked on graphics and visual arts associated with the project |
Marlene Rosell, RN, CPEN |
Clinical Nurse |
ED |
Worked on graphics and visual arts associated with the project |
Rene Bascoy, RN, CCRN, CPN |
Clinical Nurse |
Pediatric ED |
Evidence Collector |
Mariela Guzman, RN |
Clinical Nurse |
Pediatric ED |
Evidence Collector |
Denishia Dozier, RN |
Clinical Nurse |
ED |
Evidence Collector |
Florida Santos, MSN, RN, CCRN |
Clinical Nurse |
ED |
Evidence Collector |
Trishana McIntosh, RN |
Clinical Nurse |
ED |
Evidence Collector |
Letiana Severe, BSN, RN |
Clinical Nurse |
ED |
Evidence Collector |
Noel Gonzalez, RN |
Clinical Nurse |
ED |
Evidence Collector |
Geraldine Harris, BSN, RN, CEN |
Clinical Nurse |
ED |
Evidence Collector |
Lisa Smith, MSN, RN, CPEN |
Clinical Nurse |
ED |
Evidence Collector |
Jill Capodanno, BSN, RN |
Clinical Nurse |
ED |
Evidence Collector |
Manuel Osborne, MSN, RN |
Clinical Nurse |
ED |
Evidence Collector |
Sherine Crag, MSN, RN, CNML |
Director |
ED |
Provided administrative support |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Executive Sponsor |
Bill Duquette, , MPH, MT(ASCP) |
Chief Executive Officer |
Administration |
Executive Sponsor |
OUTCOME(S)
In December 2014, City Commissioner Waldman presented the SANE-trained nurses with a certificate of compassion. In the same month, Hill, together with MUJER Director Susan Rivera, delivered a presentation to a sister hospital, West Kendall Batist Hospital, regarding the partnership with MUJER and their services.
Exhibit NK4EOc: Sexual Assault Screening – Homestead Hospital
Analysis: Above graph shows that Homestead Hospital ED has seen an increase in sexual assault screenings since the initiation of its partnership with MUJER as evidenced by in increasing trend line. Additionally, the ED nurses trained on SANE have already collected 3 forensic specimens since the training was completed in September 2014.
Next Steps
Future plans include moving forward with the journey of becoming a Rape Crisis Treatment (RCT) center. This involves further refinement of the process with the development of a protocol and revision of the rape victim/sexual assault policy. Homestead Hospital also plans to engage an outside consultant to assist in conducting a gap analysis; formulating an action plan; and establishing implementation timelines. ED nurses initially educated on SANE will pursue additional training with the goal of becoming signed off as competent and certified. Hill also plans to continue monthly SANE nurses meetings in the ED.
Summary of Attachments/Hyperlinks/Evidences
Exhibit NK4EOc: Sexual Assault Screening – Homestead Hospital