SE1EO

SE1EO Clinical nurses are involved in interprofessional decision-making groups at the organizational level. (Examples include, but not limited to, organizational quality councils, budget review committees, equipment selection committee, mortality and morbidity committees, pharmacy and therapeutics committee, blood utilization committees, safety committees, and bioethics committees).

Provide two examples, with supporting evidence, of improvements resulting from the contributions of clinical nurses in interprofessional decision-making groups at the organizational level. 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

Chest Pain Center Committee

BACKGROUND/PROBLEM

Acute coronary syndrome (ACS) is a life-threatening form of coronary heart disease (CHD) that occurs when the myocardium does not receive enough oxygenated blood. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (UA). ACS affects an estimated 1.4 million people in the United States annually. (NIH Medline Plus, 2009) resulting in death or cardiac impairment that may lead to various degrees of disability.

Approximately 6% of all adult patients presenting in the Emergency Department (ED) have a chief complaint of chest pain, which is the second most common reason a patient visits the ED. Chest pain is one of the symptoms that may suggest a patient is experiencing an ACS. The Center for Medicare and Medicaid Services (CMS) has named several core measures, including AMI, with specific relevant indicators that hospitals must meet in order to avoid financial penalty for rendering care below the national benchmarks. The interprofessional Chest Pain Center committee at Homestead Hospital was the vehicle utilized to initiate and maintain Chest Pain Center accreditation, designated by the Society of Cardiovascular Patient Care.

In the Chest Pain Center accreditation 8-step model, the care of the ACS patient begins with patient’s symptom onset and includes involvement of Emergency Dispatch Services (EMS) to the ED, transfer to reperfusion facilities, if needed and continues through discharge from the facility. Facilities plan and organize care in a systematic manner using a process improvement approach.

Organizational Interprofessional Decision-Making Group

It was through the focused efforts of the Chest Pain Center committee that Homestead Hospital obtained its initial accreditation in January 2011. The Chest Pain Center committee was a hospital-wide interprofessional group consisting of various disciplines from Nursing, Performance Improvement, Laboratory, Pharmacy, Facilities Management, Imaging, Cardiology, Finance, Community Relations, Marketing, and Volunteer Services. The committee membership was comprised of leaders and direct care staff. Senior leaders, including Chief Executive Officer (CEO) Bill Duquette and Chief Nursing Officer (CNO) and Vice President Gail Gordon, RN, also sat in the committee to facilitate decisions on resource allocations and critical timelines. It was led by Patient Care Manager and Chest Pain Center Coordinator Joan Baker, RN. The committee’s purpose was to address all aspects of ACS care including financial, process improvement, quality, ACS community education and internal competencies. Specifically, its goal for FY 2012-2014 were as follows:

Assess the current state of processes in the care of ACS patients, at Homestead Hospital through the use of evidence-based practice and existing scientific standards.
Evaluate all processes through mapping and flowchart the care of ACS patients to recognize obstacles and opportunities to improve processes for the ACS patient.
Evaluate and report ACS metrics for process improvement.
Increase collaboration with EMS.
Assure best practices are integrated in medical protocols.
Improve community education through the Marketing Department.
Maintain a monthly continuing medical education (CME)/continuing education (CE) program in Cardiology at Homestead Hospital
Seek Chest Pain Accreditation in Cycle IV
Celebrate successes

GOAL STATEMENT(S)

For the Cycle IV Chest Pain Center accreditation, one of the goals that the committee focused on was improving door to EKG time less than 10 minutes from 70% to 85%.

DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)

The Chest Pain Center committee met on a quarterly basis. The team utilized the Chest Pain Center accreditation 8-step model a guide as they embarked in their journey for reaccreditation.

Community Education and Early Heart Attack Care (EHAC)

Physicians, nurses (including clinical nurses) and ED technicians provided a series of community education on heart attack warning signs, risk factors and the importance of calling 911 at various venues in the hospital, and outside as well, in the months of January 2013, July 2013 and February 2014. The committee also recruited community partners by letting them recite the Heart Attack oath. This was a community education initiative started by a physician, Dr. Barr. The focus of this oath was to obtain commitment from the community members to act on the prodromal signs of heart attack by seeking early heart attack care (EHAC).

Emergency Medical Services Integration with Emergency Services.

Chest Pain Committee members met with the EMS captain at least quarterly to review metrics; EKG and transport time fallouts; and recognitions, which the captain brought back to appropriate EMS staff. They provided education to the Miami-Dade Fire Rescue EMS responders on EKG interpretation and care of a STEMI patient being transported during hypothermia treatment in January 2014.

Emergency Assessment and Timely Diagnosis and Treatment of ACS

Clinical nurse educators and clinical nurses reviewed all 4 levels of care with ED and inpatient units. Chest Pain Committee members performed several STEMI drills in March and December 2013 and assessed actual practice on a continual basis to ensure improved outcomes.

Assessment of Patients with Low Risk for ACS and No Assignable Cause for Their Symptoms

Point-of-Care Testing (POCT) troponin turnaround time (TAT) was below the Society of Cardiovascular Patient Care standard of care and benchmark. The committee, in collaboration with the ED Unit Practice Council (UPC), implemented interventions to improve TAT. Baker met with physicians (cardiologists, hospitalists) and reviewed/revised levels of care and order sets. She also solicited clinical nurse input by posting the revised order sets for comments. The committee members educated the staff accordingly.

Process Improvement (PI)

The committee conducted a gap analysis in July 2013 using the failure mode effects analysis (FMEA). They collected metrics and reported findings at the ED staff meetings. They identified opportunities for improvement in the following processes: Door to EKG TAT, Troponin TAT, Door to Transfer TAT, Door to PCI TAT, and EMS transport. The challenge with EKG TAT was that the chest pain screening tool was not utilized consistently by the caregivers at the ED entry points (lobby and ramp) because of high patient volume. Additionally, registration staff was not recognizing signs and symptoms of chest pain, which contributed to the delay in obtaining EKGs. To specifically address door to EKG TAT, the Chest Pain Committee members met with cardiology, registration, and lobby staff in June 2013. As part of the action plan, the team decided to order an EMS radio for EKG technicians so they could hear real time EMS reports of incoming patients. This enabled them to identify patients needing an EKG even before arrival. The team also asked the cardiology department to relocate one of their EKG machines to the ramp. The registration staff was educated to refer patients with chest pain symptoms to clinical staff immediately. The details of the action plan to improve the EKG TAT were as follows:

April 2013

Provided ED, Cardiology, Registration staff education

July 2013

Included EKG screening tool in the new employee orientation checklist
Provided copies of EKG screening tool to ramp and lobby staff
Started daily rounding to reinforce why EKG screening tool was important to identify ACS patients early
Included reinforcement of screening tool in daily shift huddle
Designated an EKG technician to start tracking EKGs ordered without using the EKG screening tool

August 2013

Reviewed EKG fallouts and EKG screening tool compliance
ED nursing leadership addressed noncompliance with use of EKG screening tool

October 2013

Provided updates at ED and Cardiology staff meetings

November 2013

Held follow-up meetings with ED registration, Cardiology and ED UPC

Personnel Competencies and Training

The committee also reviewed competencies and required training with all clinical nurse educators in May 2013. To facilitate attendance, committee members conducted training at the end of staff meetings and during orientation. Baker maintained a spread sheet for tracking to ensure staff adherence to the education requirement.

Organizational Structure and Commitment

CEO Duquette affirmed his full support of the Chest Pain Center. This commitment was encapsulated in the hospital administration resolution that he signed. As such, a member of senior leadership attended at least 50% of meetings and facilitated resolution of policies and financial roadblocks.

Functional Facility Design

The Chest Pain Center Committee members together with the plant engineer conducted a walk through in October 2013 in the external and internal hospital areas to evaluate signage for appropriateness and visibility. As a result, additional signs were installed to enhance visibility of ED location in December 2013. The committee also ensured that there was adequate equipment such as iSTAT analyzers to perform POCT in a timely manner. Senior Administration and department leaders provided fiscal support ensuring that the budget was sufficient for the needed equipment.

PARTICIPANTS

Contributions of Clinical Nurses

Name/Credentials	Title	Department	Role in the Team
Nancy Doctura, BSN, RN	Clinical Nurse	ED	Chest Pain Center committee member; Participated in STEMI drills, performance improvement activities, community health fairs, and staff education
Judy Bird, MSN, RN	Clinical Nurse	ED	Chest Pain Center committee member; UPC Chair Elect; participated in STEMI drills, performance improvement activities, community health fairs, and staff education
Marvia McKenzie, RN	Clinical Nurse	ED	Participated in STEMI drills, community health fairs, and poster presentation during the Chest Pain Congress in February 2013.
Venessa Portilla, BSN, RN	Clinical Nurse	ED	Participated in ED and inpatient STEMI drills
Eduardo Zarate, BSN RN	Clinical Nurse	ED	Chest Pain Center committee member; ED UPC Chair; participated in STEMI drills, community health fairs
Joan Baker, MSN, RN, CCPC, CCRN, CNRN	Patient Care Manager and Certified Cardiovascular Care Coordinator	ED	Chest Pain Committee Chair
Aracely Olvera, BSN, RN, CMSRN	Clinical Nurse Educator	MS5	Provided staff education on levels of care; participated in inpatient STEMI drills and community health fairs
Rosemary Lee DNP, ARNP,ACNP-BC,CCNS, CCRN	Clinical Nurse Specialist	ICU/PCU	Conducted staff education
Sandra Jones, BSN, RN, CMSRN	Clinical RN Educator	3 South	Provided staff education on levels of care; participated in inpatient STEMI drills
Ann Marie Allen MS/HSA, MSN, PhD(c), RN, NEA-BC	Assistant Vice President of Nursing	Nursing Administration	Facilitated Centers for Excellence in Nursing (CEN) grant requests; provided administrative Support
Gail Gordon, MSN, RN, NEA-BC	CNO and Vice President	Administration	Provided administrative support
Jill White, RN, CPHQ	Director	Performance Improvement	Provided guidance in conducting FMEA
Cynthia Fischer, RN	Performance Improvement Nurse	Performance Improvement	Assisted in data collection for core measures
Bill Duquette, MPH, MT(ASCP)	Chief Executive Officer	Administration	Executive Sponsor
Erik Long, MBA	Regional Controller	Administration	Gave fiscal support
Corey Gold, MS, CRT	Operations Vice President	Administration	Facilitated replacement of signage
Winifred Pardo Pharm.D. , BCPS	Clinical Pharmacist	Pharmacy	Reviewed STEMI order sets and STEMI box
Anette Perry, BS, MLS	Lead Medical Technologist and POC Coordinator	Laboratory	Assisted in streamlining process for Troponin POC
Jorge Mauricio, CCT	Supervisor	Cardiology and Sleep Laboratory	Member
Paul Blake, EMTP	EMS Captain	Miami Dade Fire Rescue (MDFR)	MDFR Liaison to Homestead Hospital

OUTCOME(S)

The Society of Cardiovascular Patient Care granted Cycle IV reaccreditation to the Chest Pain Center in February 2014. Homestead hospital received very high commendations for their improved processes and patient outcomes.

Exhibit SE1EOa: Percent of Door to EKG turnaround Time of 10 Minutes or Less

Legend:

April 2013

Provided ED, Cardiology, Registration staff education

July 2013

Included EKG screening tool in the new employee orientation checklist

Provided copies of EKG screening tool to ramp and lobby staff

Started daily rounding to re-enforce why EKG screening tool was important to identify ACS patient early

Included reinforcement of screening tool in daily shift huddle

Designated EKG technician started tracking EKG ordered without screening tool

August 2013

Reviewed EKG fallouts and EKG screening tool compliance

ED nursing leadership addressed noncompliance with use of EKG screening tool

October 2013

Gave updates to the ED and Cardiology staff meetings

November 2013

Held follow-up meeting with ED registration, cardiology and ED UPC

Analysis: Above graph shows that the Chest Pain Center Committee has achieved its goal of improving door to EKG turnaround time of 10 minutes or less to 85% and sustained it for 4 consecutive months.

References

AHA Scientific Statement. Testing of Low-risk Patients Presenting to the Emergency Department with Chest Pain (2010).

Society of Cardiovascular Patient Care, Cycle IV Reaccreditation Tool (2012).

Wang, TY, et al. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA. 2011;305(24):2540-2547.

Summary of Attachments/Hyperlinks/Evidences

Exhibit SE1EOa: Percent of Door to EKG turnaround Time of 10 Minutes or Less

Example 2

NAME OF INITIATIVE

Improving Computerized Tomography (CT) Scan Turnaround Time for Stroke Patients

BACKGROUND/PROBLEM

Stroke is the 4th leading cause of death and the leading cause of disability in the United States. The National Institute of Neurological Disorders and Stroke (NINDS) conducted rigorous research to find acute stroke therapies to improve the lives of those afflicted with stroke. In 1991 due to the NINDS research, intravenous Tissue Plasminogen Activator (tPA) was approved by the FDA to treat acute ischemic stroke for those patients who qualified and presented within a 2-hour window of symptom onset. Subsequently, another subset of patients who presented within a 6-hour window was eligible for intraarterial and/or clot retrieval device treatment in a cardiac catheterization laboratory. Patients outside the acute treatment window would receive post-stroke care to overcome disabilities that resulted from stroke damage.

Organizational Interprofessional Decision-Making Group

Homestead Hospital participates in the Baptist Health South Florida (BHSF) Collaborative to improve care of stroke patients across the continuum using the American Stroke Association (ASA) Standards. Each entity has its unique infrastructure to attain patient goals. In spring 2013, in order for Homestead Hospital to meet national guidelines, a performance improvement (PI) task force convened and agreed on a stroke protocol to assess CT turnaround time for patients arriving within 2 hours of symptom onset. To formalize the process, in September 2013, the Stroke Steering Committee was formed. It was an interprofessional group that met monthly, consisting of Nursing, Pharmacy, Laboratory, Imaging, Rehabilitation, Nutrition Services; Emergency Medical Staff, Neurology, Performance Improvement and Nursing Health Sciences Research. The group was chaired by Patient Care Manager and Cardiovascular Patient Care Coordinator Joan Baker, RN who has extensive experience and expertise in the care of the neuroscience patient. She has obtained her national board certification as a neuroscience RN since 1995. Emergency Department (ED) Clinical Nurses Marvia McKenzie, RN and Nancy Doctura, RN were members of the committee.

Key indicators for efficient stroke care included early symptom recognition, appropriate and timely evaluation and appropriate patient management. Homestead Hospital’s immediate goal was to be a Stroke Ready Hospital. According to ASA, Stroke Ready hospitals provide timely access to stroke care for stroke patients who present to the facility. The Stroke Steering Committee’s initial goal was to begin early diagnostic evaluation for patients arriving within 2 hours of symptom onset. A computerized tomography (CT) scan provides critical information on the type of stroke a patient has, and helps clinicians determine whether tPA should be given. Homestead Hospital monitors the median time from ED arrival to initiation of brain imaging by CT scan. In January 2014, CT scan median turnaround time for patients arriving within 2 hours of symptom onset ranged between 67-85 minutes. American Heart Association (AHA) and ASA 2013 guidelines recommended within 25 minutes of arrival in the ED.

GOAL STATEMENT(S)

The Stroke Committee’s overarching goal was to improve processes on early stroke recognition and timely diagnostic work up. Specifically, they aimed to decrease CT scan turnaround median time from 60-80 minutes to less than 45 minutes of ED arrival. The median time is the time by which half of the patients have been scanned (lower times are better).

DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)

Prior to the actual formation of the Stroke Steering Committee, in February 2013, Baker worked in conjunction with the ED Stroke Physician Champion Mark Weinstein, MD to develop a stroke checklist consisting of actions and timelines to deliver the standard of care to all stroke patients arriving at the facility for treatment. They also worked on implementing an ED Stroke Alert protocol that notified all members of the Code Team of the arrival of an acute stroke patient in the ED. This protocol was implemented in the ED in March 2013.

Baker identified noticeable delays in CT scan and laboratory turnaround times. Physicians needed the results of these diagnostic studies to decide on the treatment plan. Baker, together with a team of ED nurses, worked on addressing identified barriers related to delayed CT scan results. First, the CT scan technician was not always made aware of a suspected stroke patient who was in need of an emergent CT scan. This patient needed an emergent interpretation and immediate communication of results to the ED physician. To address this, the group decided that the ordering physicians must write “Stroke Alert” on the physician order comments section together with their phone number. The neuroradiologist would then immediately call the ordering physician’s phone to verbally communicate the results of the plain brain CT scan. This process also became effective in March 2013.

Since Homestead Hospital was not a stroke certified hospital, no written protocol existed with the Miami Dade Fire Rescue (MDFR) to expedite a patient presenting with stroke like symptoms to the CT scan. However, there was an established process for instances when stable patients with suspected stroke symptoms would be brought to Homestead Hospital. In those cases, MDFR would relay the chief complaint to the ramp nurse who performed a rapid assessment to validate stroke symptoms and referred patients to the physician for further assessment and diagnostic workup.

Having interprofessional membership in the Stroke Steering Committee was useful in identifying opportunity areas. Additionally, establishing a formalized committee structure with hospital-wide representation enabled the committee to better advocate for key stakeholder buy-in with the implemented tactics. Whereas previous data were done on patients presenting within 6 hours of symptom onset, the committee decided to start monitoring data on patients presenting within 2 hours of symptom onset. Clinical Nurses Marvia McKenzie, RN and Nancy Doctura, RN assisted in the data collection by conducting stroke case reviews. They noted that median CT result turnaround times for this patient subgroup were above 60 minutes despite the aforementioned processes that were put into place. Thus, the initial meetings of the committee focused on identifying contributing factors to delays in this process. In September 2013, the committee performed a gap analysis at Homestead Hospital using the Agency for Health Care Administration (AHCA) standards. The team noted gaps in nurses’ education on stroke assessment and care and the need for a stroke team to respond to stroke alerts. Despite the education previously done on the ED stroke protocol and the process changes implemented, adherence by the ED nurses, technicians and some physicians to the protocol was very low. For this reason, the committee campaigned for a more comprehensive education intervention at the hospital-wide level and targeted education at the ED level to support the initial education.

The committee obtained approval for an expanded stroke education that involved not only the ED employees but the rest of the hospital staff. This was a major initiative to increase staff awareness of the guidelines, ED stroke protocol and NIH stroke scale. The education took place between January and May 2014. The committee provided stroke badge buddies to all employees who were also required to take a mandatory online module on stroke symptoms recognition via Baptist Health University (BHU). To specifically address the CT scan turnaround time, Baker, along with Clinical Nurses McKenzie and Doctura, gave targeted ED staff education during shift huddles, rounds, staff meetings and one-on-ones. They also reintroduced the Stroke Alert checklist that was implemented the year before. The committee monitored data monthly and provided feedback to departments involved.

PARTICIPANTS

Contributions of Clinical Nurses

Name/Credentials	Title	Department	Role in the Team
Joan F Baker, MSN, RN, CCRN, CNRN, CCPC	Patient Care Manager and Cardiovascular Patient Care Coordinator	Emergency Department	Stroke Coordinator and Chair
Marvia McKenzie, RN	Clinical Nurse	Emergency Department	Performed stroke case review, educate ED clinical staff on stroke protocol; member
Nancy Doctura, BSN, RN	Clinical Nurse	Emergency Department	Performed stroke case review, educate ED clinical staff on stroke protocol; member
Rusette Arends, BSN, RN, CPEN	Clinical Nurse Educator	Emergency Department	Educated ED clinical staff on stroke protocol; member
Rosemary Lee, DNP, ARNP, ACNP-BC, CCNS, CCRN	Clinical Nurse Specialist	Critical Care	Educated inpatient clinical staff on stroke protocol; member
Gail Gordon, MSN, RN, NEA-BC	Chief Nursing Officer and VP of Nursing	Administration	Executive Sponsor; member
Aracely Olvera, BSN, RN, CMSRN	Clinical Nurse Educator	MS5	Educated inpatient clinical staff on stroke protocol; member
Leslie Everett, BSN, RN	Nurse Manager	Critical Care	Educated inpatient clinical staff on stroke protocol; member
Ana Cabrera DNP, ARNP-BC, CCRN, NEA-BC	Assistant Vice President of Nursing	Nursing Administration	Provided administrative support; member
Alicia Browne- Rowe, BSN, RN	Special Projects Coordinator	ICU	Member
Maria Ojeda, DNP, PhD-(c), MPH, ARNP, NP-C	Nurse Scientist	Nursing and Health Sciences Research	Data Collection; Consultant
Andrea Draizer, SLP	Speech Language Pathologist	Rehabilitation Services	Member
Kurt Kadel, PT	Director	Rehabilitation Services	Member
Mary Shaw, RD	Registered Dietician	Dietary	Member
Raul Lorie, RT	Director	Imaging Services	Member
Eduardo Plasencia	Imaging Information System Technician	Imaging Services	Assisted with data collection; member
Elka Wiley, MD	Neurologist	Medical Staff	Physician Stroke Champion; member
Mark Weinstein, MD	Emergency Medicine	Medical Staff	Physician Stroke Champion; member

OUTCOME(S)

Exhibit SE1EOb: Homestead Hospital Median CT Turnaround Time for ED Stroke Patients

Analysis: Above graph depicts that the committee has met its goal of decreasing the CT scan median turnaround time from 60-80 minutes to less than 45 minutes and sustained it for 4 consecutive months after the coordinated hospital-wide and targeted ED stroke education implementation.

References

Stroke. 2013; 44: 870-947 Published online before print January 31, 2013, doi: 10.1161/STR.0b013e31828405

Summary of Attachments/Hyperlinks/Evidences

Exhibit SE1EOb: Homestead Hospital Median CT Turnaround Time for ED Stroke Patients

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