The New England Nursing Informatics Consortium (NENIC; http://www.nenic.org/) is an active nursing informatics organization. The primary mission of NENIC is to "Transform Health Care Through Informatics," and the strategies to accomplish this mission include (1) providing forums for resource and information exchange, (2) providing educational opportunities in the field of nursing and healthcare information systems, and (3) exploring the role of nursing in the integration of information systems into the healthcare environment. The theme of the 14th annual symposium, "Trends in Clinical Informatics: A Nursing Perspective," mirrored the organizational mission: nurses transforming healthcare through informatics. This program is one of the annual NENIC educational events and offers lectures from local and national leaders, posters, networking opportunities, and access to leading technology solutions. (For access to past symposiums and posters, visit the NENIC Innovation Library at http://www.nenic.org/innovation-library).
The poster presentations are always popular, and this year was no exception. This effort showcased local best practices, and the voices of New England nurse informaticists. Members of NENIC Karen Bavuso, MSN, RN, and Rita Zielstorff MS, RN, FACMI, facilitated the NENIC Call for Participation and supported the development of each poster. The poster sessions are extended by the "Member Highlights" panel, which places an emphasis on work that is innovative, topically relevant, and sophisticated in thought and organization and demonstrates leadership or offers unique solutions. It encourages deeper discussion and exploration of how informatics and technology are being used to improve patient care and safety. Here are NENIC's 2016 Member Highlight presentations:
The Use of Tablet Technology for Real-Time Patient Feedback
Leslie Hutchins MBA, BSN, RN, and Carol Salerno BSN, RN
Introduction/Background: To obtain real-time patient feedback during the hospital stay or ambulatory visit, we implemented a tablet technology and software that allowed patients and families to easily communicate compliments and opportunities for improvement. The goal was to provide staff with an effective, real-time opportunity to assess, intervene and remedy issues as they arise.
Project Description: Using a vendor supplied application, real-time feedback analytics were provided and allowed patients and families to provide compliments and opportunities with the use of a tablet during their hospital stay or ambulatory visit.
Patients were provided with a tablet on a daily basis during their hospital stay. The key features for the use of this resource were as follows:
* Fast, simple, customized questionnaire (four to five questions that take less than 60 minutes to complete)
* Instant e-mail/text alerts for both comments and opportunities
* Live dashboards in the clinical setting, available for viewing the real-time feedback by the interdisciplinary care team
* Leadership access to the application portal for custom reporting/data analysis
Project Methods: The tablet technology was initially piloted on a single unit for 1 year. Following this introduction into the clinical setting, additional pilot units were designated (medical, surgical, pediatrics, ambulatory, and lab draw stations) in August 2015.
The Project Team assisted with the following:
* Configuration of the standardized questions for inpatient, outpatient, pediatrics, and the lab draw station, allowing for the unique environment/clients in each setting
* Designating the number of tablets and charging station placement for the unit/department
* Hardware installation: unit dashboard placement
* Script for staff to utilize when distributing the tablet/questionnaire
* Alert notification process for weekday and weekends
* Portal access for directors, managers, and assistant managers
Weekly Webinars were scheduled for the participants to provide feedback and obtain additional support as needed to sustain the implementation on their unit/department.
Results/Conclusion: The tablet technology tool provides real-time results for real-time service recovery. The unit/department leadership team is notified when the score is below 60, the comment is either an opportunity or a request through the use of tools that query the content and able to denote the comment sentiment (positive, negative, request).
The team recognized an opportunity for real-time feedback to go directly to the appropriate resource for real-time resolution utilizing the vendor supplied technology and notification process. This quality improvement tool requires an established daily workflow to address opportunities and promote a culture for quality and safety.
Using Clinical Decision Support in an EHR to Facilitate a Nurse-Driven Protocol
Jeanne Praetsch, MS, RN, Laurie Cairns, MS, Debra Furlong, MS, RN, Casey McGrath, MSN, RN, Deborah Mulloy, PhD, RN, Marc Pimentel, MD, Vincent Vacca, MSN, RN, and Denise Goldsmith, MPH, MS, RN
Introduction/Background: It is well known that the use of indwelling urinary catheters (IUCs) during an acute hospitalization increases the risk of catheter-associated urinary tract infection (CAUTI). Reducing the length of catheterization (catheter-days) can reduce CAUTI risk.1,2 Prior to the implementation of an integrated electronic health record (EHR) at this academic medical center, a nurse-driven protocol (NDP) for IUC removal had been implemented utilizing a hybrid approach with electronic decision support for the ordering of the protocol and a paper flow sheet for documentation. This protocol effectively reduced catheter days by 11% in early 2015. Implementation of a new EHR created new workflows for ordering and documentation and some software "bugs" that led to a decrease in the ordering and documentation of IUCs and the use of the NDP. The work described here was initiated to recoup or surpass previously obtained outcomes.
Methods: To address the issues resulting from the implementation of our EHR, interprofessional collaboration was employed to identify specific problems and possible electronic solutions. Issues that were addressed included redundant order sets, suppressed CDS Best Practice Alerts (BPAs), nursing work list prompts, and related flow sheet documentation. Upon completion and before activation of software modifications, reference sheets and education were provided.
Results: Order sets were simplified and standardized across phases of care. They were modified to provide clarifying language related to IUC care orders in the emergency department order sets and required entry of a specific date and time for the removal of IUC in post-op order sets. The CDS BPA was modified to trigger the morning after an IUC order is placed. This BPA requires the ordering provider to choose either to discontinue the catheter "now" or to order the NDP for removal of IUC. Improvements to the flow sheet and work list included the following:
* When NDP is ordered, a "reason for continuation" row automatically populates the flow sheet.
* A work list task prompts the nurse (every 8 hours) to utilize the NDP for assessment of NDP exclusion criteria.
[white circle] Presence of exclusion criteria requires ongoing use of the IUC
[white circle] Absence of exclusion criteria initiates the NDP and removal of the IUC
* Documentation of this assessment from the flow sheet or the work list now satisfies the NDP requirements.
* A link to the NDP for IUC Removal Policy and algorithm (utilized for decision support and next steps after catheter removal) was built into the EHR.
The EHR and workflow modifications led to a sustained 14% decrease in catheter-days, surpassing previous performance of the NDP.
Discussion/Conclusion: The implications of a new electronic health system can greatly impact work flow and potentially jeopardize existing quality improvement projects. The goal of these EHR modifications was to facilitate care providers in the ordering, assessment, and documentation for appropriate urinary catheter usage and utilizing an NDP for urinary catheter removal. These improvements were accomplished through interprofessional collaboration and a shared vision to achieve or surpass previous performance.
Staffing Ratios Using an Acuity Tool
Andrea Santos RN, BSN, MSHI, and Diane Menasco RN, BSN, MSHI
Introduction/Background: Nursing care is more than a staffing ratio, yet an ICU staffing mandate was successfully written into Massachusetts law in 2014.3,4 North Shore Medical Center (NSMC) had been using an acuity tool since 2002, as well as an assignment feature since 2013, to create medical/surgical nursing assignments. All Partners acute and rehab hospitals use the acuity tool for tracking patient acuity. However, not all Massachusetts Health Policy Commission (HPC) regulations could be met using the existing version of the acuity tool. For example, the system could not denote whether the patient should have a 1:1 or 1:2 ratio for nurse assignment.
Methods: Partners acuity tool council met for a strategy session with the acuity tool developers. A new version of the tool was drafted using input from the Partners Council that included input from NSMC charge nurse interviews and lessons learned. The acuity tool provided an update to the product that NSMC beta tested in December 2015. The acuity tool update was implemented by NSMC in February 2016. In March 2016, the ICU implemented the assignment feature for patient ratios in accordance with HPC requirements. The acuity tool uses an objective classification process using 24 indicators to quantify patient care needs for the next 12-hour shift. Nurses are required to complete a classification on their patients based upon the patients' anticipated care needs for the next 12 hours. This calculates the patient's workload for direct nursing care, which is used to determine nurse-to-patient ratios for the ICU nursing assignments.
Results: The assignment feature uses the selected indicators for each patient to calculate patient workload. The patient workload is then used to determine the patient ratio, 1:1 or 1:2 assignments for the ICU nurse. The patient ratios are denoted next to a patient name with R1:1 or R1:2. In addition to using ratios, other factors including continuity of care, isolation patients, and environmental factors, such as the physical layout of the unit, are taken into account when creating nursing assignments.
Discussion/Conclusion: In using the enhanced version of the acuity tool, NSMC is meeting the current HPC regulations. Details for public reporting have yet to be finalized by the HPC. The assignment feature is meeting the goals of the ICU staffing committee and the ICU staff nurses.
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