Embed Size (px)
Citation preview
Nursing’s Annual Report
We are MagnetTM!
My Nursing Colleagues,
Wow, another year has past and as I reflect back to what was accomplished during this year, I remain in awe of the capabilities and commitment of the individuals employed at Billings Clinic. 2009 was a year of unprecedented challenges, with an unpredicted recession that rocked the financial position of many organizations including Billings Clinic. Challenges that many of us have never had to face before in our careers. As a team we had to work better together, sacrifice together, and survive the challenge together. Together we were able to accomplish what we had planned. Critical to our success was our ability to motivate the team, define direction, and keep our goals in mind. In spite of many difficult months, together we accomplished our overarching goal of maintaining employment for all Billings Clinic staff.
So what were the key lessons learned during this time? First and foremost, I believe our commitment to each staff member in the organization was clear. The importance of qualified staff is what makes Billings Clinic the organization it is today. Not the brick or mortar, the human side of caring: your touch, your kind word, you! To achieve our vision around quality, safety and service, this organization needs you. So even if you did not agree with the path chosen, I sincerely hope you recognized that the commitment to each individual staff member was sincere. Secondly, in spite of the difficult challenges, our commitment to quality, safety, and service did not waver. I vividly recall our Personal Service Excellence (PSE) 2010 initiative, staying true to our service promise, and engaging staff from all areas in the “show”. The work of many wonderful teams helped us reduce MRSA rates, decrease decubitus rates, decrease restraint use and decrease length of stay. We continue to move forward with automation and the quest of a fully integrated electronic medical record, a project which will span the next several years. The team learned the value of identifying waste with lean, six sigma training. For example, the work completed around the discharge process and follow
up phone calls to inpatients that were discharged improved patients’ perception of their readiness for discharge and improved the patients’ satisfaction with discharge. Again the human side of the personal phone call reassured the patient of discharge instructions, identifying possible complications and assuring compliance with medication management. This was only one of many successful projects completed by very dedicated staff throughout the organization. The challenges were many, some even persist today. However our efforts in theses areas did not stagnate. With your commitment and hard work, our quest to be a national leader in quality, safety and service did not get lost, the commitment strengthened. Our third lesson was the power of the team. The financial challenges and decisions that had to be made were very difficult. But difficult times can build character in a team. We had to trust each other to do the right thing for the organization as a whole. The importance of communication could not be underscored. Weekly, monthly and quarterly communications became the norm. Our commitment to engage staff around improvement was never stronger. As a member of the executive team, our commitment to restore benefits that were withheld was on our minds every day! The challenging months seemed like a lifetime. In a way changing direction in health care is like turning the Titanic: slow, awkward, and at times it seemed impossible. But as a team we weathered the storm. I started this message to you by using the word “together” and I want to draw this to closure using the same word: together. Together we were successful! Together we faced a challenging time, and mastered that difficult time. I could not be prouder of the nursing team in this organization for the fortitude and perseverance shown during this time. We know that there are additional challenges coming toward us with health care reform. I am sincerely grateful that I am a part of this team, because no matter what the future holds for us, I know we will get through it “together.”
To nursing colleagues external to Billings Clinic I sincerely hope that you have time to reflect on what is shared in this annual report. The information is only a snapshot of the wonderful things nursing staff at Billings Clinic have accomplished this year. To my nursing staff this message was written to you. Thank you from the bottom of my heart for everything you do every day. As I have said before you are Billings Clinic and I am proud to be a part of your team. Enjoy!
Always,
Lu
Who We Are
Lu Byrd, RN, MNBillings Clinic Vice President of Hospital Operations and CNO
Table of Contents
Letter from Lu Byrd, RN, MN, CNO i
About Billings Clinic iii
Professional Practice Model 1
What is this Thing, The Professional Practice Model? 2Nursing’s Strategic Plan 4
Building Our Future 6
Inpatient Cancer Care Unit…a Healing Environment 7Reproductive Medicine and Fertility Care 8Lateral Integration 9Physical Expansion/ Expanded Level of Care NICU 10Pediatric Nurse Clinician/Virtual Pediatric Unit 11Novice to Expert 12Surgery Center Off and Running! 14New Medical/Surgical Nurse Clinician 15Optilink Staff Runner 16
Nursing Quality and Research 17
Pressure Ulcer Prevention (PUP) Team 18Fall Prevention at Billings Clinic 21Reduction in Patient Length of Stay Project 22Boston University Pressure Ulcer Research Project 24Creating Best Practices in Managing Hypertension Education and Health Information Technology 26
Caring is Contagious 30
Family Medicine Billings Clinic Red Lodge 31An International Nursing Experience 32
Letter from Nicholas Wolter, MD, CEO 35
••
•••••••••
•••••
••
i ii
Billings Clinic’s total service area comprises 40 counties in eastern Montana and northern Wyoming and covers approximately 121,000 square miles. Billings Clinic branch locations include:
Based in Billings, Montana, Billings Clinic is a community governed, not-for-profit multi- specialty group practice integrated with a 272-bed hospital, long-term care facility, and more than 3,500 employees, including 247 physicians, 45 physician assistants, 26 nurse practitioners, and over 900 registered nurses.
Billings Clinic offers 46 specialty services, including our Level II Emergency & Trauma Center, Cancer Center, Family Birth Center, Orthopedics and Sports Medicine Center, Cardiovascular Services, Neurosciences, Women’s and Children’s Services, Surgery, Psychiatric Services and Primary Care.
We have innovative technology that improves patient care, safety and access, including a Clinical Information System with one electronic medical record in all clinic and hospital locations.
•
•
•
Serving Our Region
Billings Clinic CodyBillings Clinic ColumbusBillings Clinic HeightsBillings Clinic Miles CityBillings Clinic Red LodgeBillings Clinic WestBozeman OB/GYN
•••••••
Eastern Montana Telemedicine Network operates 36 sites in 26 communities.
Billings Clinic MedFlight advanced life support fixed-wing aircraft service transports critically ill or injured patients from rural communities.
Our Family Birth Center provides family-centered care in beautiful birth suites and a Level IIIa NICU. More than 1,400 babies are born here each year.
The Billings Clinic Research Center is in the business of answering important questions which will improve the health of our patients through clinical research studies. Volunteers can participate in phase I, II, III, and IV clinical trials designed to study the latest investigational medications and devices in patients with such conditions as diabetes, multiple sclerosis, osteoporosis, hypertension, gout, vascular disease and women’s studies.
•
•
•
•
About Billings Clinic
Professional Practice
Model
1iii
Professional Practice Model
VISION
Nursing Excellence
CARE DELIVERY
MODEL
Patient/Family
Centered Care
LEADERSHIP STRUCTURE
Shared Governance
FOUNDATION
Nursing Strategic
Plan
What is this Thing, The Professional Practice Model?When asked to explain the Professional Practice Model (PPM) and why it is important to have a model, I like to make a comparison to the concept of building a dream home. You spend time planning what you need and what is important to make your home meet the current and future needs of you and your family. You are faced with many challenges and many decisions; how many bedrooms, how many bathrooms, formal living room or large family room, large kitchen or small kitchen, large lot or condominium, etc. You often don’t make the decisions alone, but are part of a team that helps accomplish your dreams. Obviously you are an integral part, but you need expertise that you might not possess. You plan what you would like with your family and reach out to individuals who can help you; architects, contractors, realtors, suppliers. Planning and designing are crucial elements to help you attain your desired goals and to materialize your vision for this dream home. So the structural plans guide the completion and attainment of your goals: four bedrooms, three baths, formal living room and dining room, eat in kitchen, large fenced-in yard. Even when buying a home, you try to match your needs as closely as possible to a design (structure). Functionally that allows you to meet as many of your personal goals as possible. So design and modeling are actually the key elements to building a strong functional structure that helps our nursing organization meet our goals and complete our work in an organized fashion. New employees have to choose an organization (structure) that best suits their professional goals very similarly to choosing a home that best suits your needs.
Developing a structure to support the work of a dynamic nursing division is just as complex as building a structure for you personally. But without the structure the ability to organize and accomplish workflow that needs to occur in “our home” would not happen. The Nursing Strategic Plan can be compared to the foundation of the home that would be “poured” to support the structure of the PPM. Our organization’s vision drives the key cornerstones. Transformational leadership, exemplary professional practice, service excellence, patient/family centered care, and
professional development/empowerment are the “bedrooms, bathrooms, and kitchen in our home” and are embedded in the foundational cornerstones. Shared Governance is the leadership model utilized to support the PPM structure and is found in the pillars of the structure. Since the integration of the Clinic, nursing leadership has engaged in planning a structure that guides the attainment of goals outlined in the Nursing Strategic Plan. The primary fiber of the leadership model is staff engagement in decisions that impact their nursing practice. The council structure, starting with the unit based partnership councils, allows us to reach out to many professional nurses to tap their expertise in meeting our goals. The Strategic Nursing Plan and the Shared Governance Structure then support the delivery of patient centered care. Once again quality, education, research, practice and leadership are key elements in providing patient centered care. The overall structure starting with the foundation, through the functioning councils ultimately leads to evidence based practice which allows us to deliver the highest quality care to the patient, our vision. So without your involvement this organization cannot be successful. The truth is it takes all of us working together to have a “solid home” and to attain our vision of providing patient/family centered care through evidence based professional practice. The PPM model is depicted on the following page.
So I hope this analogy helps you understand the importance of having a strategic plan, leadership structure, care delivery model and a vision. These components together make the Professional Practice Model. The model (structure) allows “our family” to accomplish “our work” to provide quality safe care with professional service to our patients. I am proud of the work we accomplish as a nursing team. I am proud of each of you and the contributions that you make every day. I realize that you touch so many lives, and your commitment is what makes Billings Clinic successful. I am proud to be a part of your team!!
With much respect,
Lu
Professional Practice Model
NURSING SENATE
PROFESSIONAL PRACTICE MODELNURSING EXCELLENCE
EVIDENCE BASED PRACTICE
3/12/10
CLIN
ICA
L PR
ACTI
CE C
OU
NCI
LS/
PART
NER
SHIP
CO
UN
CILS
EDU
CATI
ON
CO
UN
CIL
PSL/
CSL
DIR
ECTO
RS C
OU
NCI
LS
NU
RSIN
G R
ESEA
RCH
COU
NCI
L
QU
ALI
TY &
SA
FETY
COU
NCI
LS
TRANSFORMATIONALLEADERSHIP
EXEMPLARYPROFESSIONAL
PRACTICE
PATIENT/FAMILYCENTERED
CARE
PROFESSIONALDEVELOPMENT/EMPOWERMENT
SERVICEEXCELLENCE
NURSING STRATEGIC PLAN
PATIENTCENTERED
CARE
QUALITY EDUCATION
LEADERSHIPRESEA
RCH
PRAC
TICE
2 3
Professional Practice Model
Nursing’s Strategic PlanBillings Clinic nursing shares the same mission, vision and values as the overall organization which drives the development of the Nursing Strategic Plan. The organization’s mission is Health Care, Education, and Research; and the vision states that Billings Clinic will be a national leader in providing the best clinical quality, patient safety, service and value. The mission and vision are reflected in the values and descriptions of Billings Clinic. The values are visible throughout the organization, and include:
Quality - Billings Clinic is committed to a high standard of quality and value to achieve optimal clinical outcomes
Service - Billings Clinic’s goal is to deliver outstanding service to its patients and communities in the region by anticipating their needs with compassion
People - Billings Clinic respects and values each individual
Teamwork - Each individual contributes as a member of the team accomplishing more than any individual can alone
Integrity - Billings Clinic takes responsibility for its actions and communicates openly and honestly with its employees and the public
Billings Clinic is an integrated foundation model built upon the cornerstones of a multi-specialty physician group practice, partnering of physicians and clinical staff, and transformational leaders and volunteers, whose synergies drive success. It is a not-for-profit community-owned and governed organization. Decision making is mission driven and dedicated to a higher purpose in the community and the staff has an obsessive dedication to quality and service. The organizational strategic plan is based on the following ten key strategies:
Patient Safety and Clinical Excellence
Personal Service Excellence
Innovation
Operational Improvement
Physician Leadership
Organizational Culture
Information Systems Solutions
Our People
•
•
•
•
•
•
•
•
•
•
•
•
•
Financial Strength and Community Stewardship
Net Revenue Growth
The mission, vision, and values at Billings Clinic are reflected in the Nursing Strategic Plan and the Professional Practice Model (PPM). Cornerstones of Transformational Leadership, Exemplary Professional Practice, Service Excellence, Patient and Family Centered Care, Professional Development and Empowerment, provide the foundation of the Nursing Strategic Plan, which aligns with the mission, vision, and strategic plan of the organization. The councils identified in the PPM provide the structure to execute the strategies in the strategic plan.
The CNO, Lu Byrd, RN, MN, is one of the executive champions of organizational strategic initiatives for patient safety, personal service excellence, and operational excellence, while supporting the other seven key strategies. She guides nursing leadership in developing strategies to support the organizational plan and driving key initiatives for the practice of nursing. The Nursing Strategic Plan development begins at the annual day-long nursing leadership retreat. The annual retreat is facilitated by the CNO and attended by directors, managers, clinical coordinators, and educators/nurse clinicians/clinical nurse specialists (CNS). During the retreat, nursing leaders engage in a process that focuses on key drivers of nursing excellence tied directly to the organizational mission, vision, values and strategic plans.
The key drivers of the Nursing Strategic Plan are:
Transformational Leadership
Exemplary Professional Practice
Service Excellence
Patient/Family Centered Care
Professional Development and Empowerment.
Over the lifetime of the strategic plan, nursing leadership will guide and direct the nursing team to focus on patient and family centered care, which is at the core of the gold star standard of nursing excellence at Billings Clinic. The integrated organizational and nursing quality plans are embedded in the Billings Clinic Plan of Care and Service which identifies the alignment of nursing’s performance improvement and quality initiatives with the organization’s quality plan. This is executed by the nursing Quality Council.
•
•
•
•
•
•
•
Professional Practice Model
Level 5Life-long
learning and development;
job satisfaction; collaborative
practice; retention;benchmark outcomes
are surpassed
Level 4Investment in employee health;
child care; sick childcare;health club opportunities; etc.
Level 3Certi�cation; professional organization membership;
clinical ladder; leadership development
Level 2Education and sta� training;
healing physical environment; recognition by the organization;positive work environment
Level 1Work safety; physical environment; organization standards;
work resources (computers, equipment, supplies, etc.);adequate sta�ng and sta�ng models; compensation
4 5
Building Our Future
Inpatient Cancer Care Unit… a Healing EnvironmentThe new Inpatient Cancer Care Unit, which opened February 2009, is a 23,000 square foot facility that provides 26 inpatient oncology beds, including capacity for a 12-bed neutropenic area. Evidence-based design was utilized to provide patient, family and nurse zones to enhance space functionality. Research led to functional yet soothing lighting options, natural light/view, on-site accommodations for family support, decentralized nursing stations, patient education libraries and a well-equipped kitchenette where families may prepare meals for long-term cancer patients.
Lu Byrd, RN, MN, CNO collaborated with nursing leadership and direct-care RNs to ensure that critical features were not missed or deleted. The features include:
Windows in patient room doors allowing nurses to visually check patients without entering the room, especially at night. Nurses also requested this feature to enhance the well-being of patients hospitalized for extended periods to decrease feelings of claustrophobia.
Continuous handrails from the patient’s bed to the bathroom allowing improved mobility and patient safety.
•
•
A fully automated mechanical lift system in all patient rooms.
Bathroom doors that will allow the mechanical lift system to extend into the patient’s bathroom while the door is shut to maintain privacy.
Patient room and hallway-access to linen and supply closets, allowing staff to adequately stock closets without disrupting patients and families.
Sliding drawers to hold trash receptacles to create a cleaner, less cluttered environment for patients and families.
Drop-down desks at the bedside to allow nurses to enter information into laptop computers without turning their backs to patients.
These features were planned by the entire design team, including direct-care RNs. The outcome of this evidence based design work is a state-of-the-art inpatient Cancer Care unit where nurses are able to practice in a setting that nurtures and provides a healing environment to not only the patients who find themselves in need of this care but also their families and those who support their journey.
•
•
•
•
•
The nursing stations on Billings Clinic’s Inpatient Cancer Care Unit were designed for efficiency and communication among nursing staff.
Oncology Clinical Nurse Specialist Jeanine Brant, PhD, APRN, AOCN, and Oncology Nurse Kerry Nichols, RN-C, care for a cancer patient in a patient room on the Inpatient Cancer Care Unit.
Building Our
Future
6 7
Building Our Future
Lateral IntegrationThe business definition of lateral integration is, “the linking together of formerly independent units engaged at the same level of production.” So how does that relate to us here at Billings Clinic? We are a health care organization that centers care on the patient, with specialized focuses based on diagnosis. Clinical Information Systems (CIS) - Cerner allows us a common database to share this patient/family information throughout the continuum of care and the lifespan of the patient no matter the location.
Currently the following areas within Billings Clinic are utilizing this database:
Radiology
Laboratory
Pharmacy
Emergency Department (ED)
Medical-Surgical Nursing
Psychiatry
Transitional Care Unit
Physical Therapy
These units all have access to the database, and add to it in limited ways (example: updating allergies, medication lists,
•
•
•
•
•
•
•
•
using eMAR, entering orders, etc.) The groups listed below have opportunities to move their documentation on-line in the near future:
Dialysis
Endoscopy
Radiology
Cath Lab
The advantages to the patient are that once they are seen at one point in the system, that information is updated in the electronic medical record, and available to all caregivers as they move to receive care from other providers throughout the system.
There is ONE allergy list, ONE medication profile….ONE record. No more will each clinic area and hospital area maintain their own record for the patient which may not all contain the same pieces of information.
When the patient enters the Emergency Department (ED) and the nurses are charting their assessment, they utilize the same charting elements as they will in the ICU and then later on as the patient moves to the medical-surgical unit. Therefore the lung assessment done in the ED can be seen by all of nursing and trends in patient condition are more easily identified.
In the future we will be taking this one step further, and the documentation will occur in context, therefore the nurse will see past results for their assessment parameters in the same view as they are charting the current assessment, thus allowing for even quicker alerts to changes in trends in the patient assessment.
•
•
•
•
Speech Therapy
Recovery
Main OR
Intensive Care Unit (ICU)
•
•
•
•
Hospital Surgery/ Pre-Admissions Testing
Dietitians
Care Management
Occupational Therapy
Surgery Center
Ambulatory Care Clinics
SameDay Care
Respiratory Therapy
•
•
•
•
•
•
•
•
Building Our Future
Reproductive Medicine and Fertility Care - Starting a New ServiceAfter helping women through pregnancy and childbirth over the past 10 years as a registered nurse, Zoey Hallam started over in a new specialty in July of 2009. She is now the nurse for Dr. Christopher Montville, Billings Clinic’s new ob/gyn subspecialist for reproductive medicine and fertility care. Previously she worked as a labor and delivery nurse, an ob/gyn office nurse, and a certified childbirth education coordinator.
“When I heard we were going to start offering fertility care, I realized I was ready for a change from hospital care and childbirth ed. I wanted a new challenge but I still loved women’s health and nursing. After several months in this new specialty, I feel I made the right choice,” said Zoey.
With help from a Friends of Nursing scholarship, she went to the American Society for Reproductive Medicine conference in the fall of 2009 to learn the big picture about reproductive medicine. She learns new skills with daily practice.
“Each day I continue to do patient education at appointments and with frequent phone calls with patients, helping them through each month, cycle-to-cycle,” said Zoey. “I touch base with our patients at least once a week for the first few weeks until we figure out their cycles. I also help with office-based procedures like intrauterine insemination (IUI) and saline-infused hysterosonograms to look for abnormalities on the inside of the uterus.”
A new job in a new department held some surprises for Zoey. “I soon discovered this job would be 24 hours a day, seven days a week. Women are giving themselves injections at home so they have questions. They don’t know when they are going to ovulate. You get calls from women who have started to ovulate (an at-home test shows an LH surge) so we have to quickly schedule an IUI procedure for the next day.”
“It’s not difficult,” says Zoey. “But I have to check voicemail every day, even on the weekends. I had two calls on Christmas Day. I have a Blackberry now and make orders from home. There is not another nurse trained to help Dr. Montville, so it can be hard to take a vacation.”
Another big challenge is working in the only practice providing this service for a huge region. There is not another reproductive endocrinologist in all of Montana, Wyoming or western North Dakota. Dr. Montville offers outreach clinics at Bozeman OB/GYN, Billings Clinic Miles City and Billings Clinic Cody. Zoey travels with him to Cody, Wyoming, each month, since there isn’t an ob/gyn nurse available to assist him.
“I spend a lot of time on the phone coordinating care with couples and their doctors,” said Zoey. “We determine what tests they can get done in their home town, trying to get as much as possible done in their community before they travel to Billings. We have more and more patients coming from out of town, so I’m talking to their local hospitals about how to get the ultrasounds and lab tests they need.”
Dr. Montville is hoping to offer in vitro fertilization (IVF) by early fall 2010. Once IVF is offered, Zoey will help with IVF education, educate patients about medications, teach patients to give themselves injections and how to time their cycle. After an IVF procedure, patients will need to come into the office every day or two for blood draw or ultrasound.
For patients who become pregnant after infertility treatments or procedures, Dr. Montville and Zoey monitor them during the first trimester of their pregnancy, and then women continue to see their own ob/gyn or family physician during pregnancy and childbirth.
“The couples I talk to are excited to have Dr. Montville here so they don’t have to travel all the way to Seattle or Denver for infertility care,” Zoey added. “In the coming year, I am looking forward to meeting all the new babies!”
Zoey Hallam, RNReproductive medicine and fertility care
The REI Lab draft where invitro procedures will take place.
8 9
Building Our FutureBuilding Our Future
Physical Expansion/ Expanded Level of Care - NICU
History
On September 1, 2008, Billings Clinic Neonatal Intensive Care Unit (NICU) brought Dr. Nadine Seger, neonatologist, to our physician team as medical director. At that time, the NICU expanded its level of care from a Level IIb to a Level IIIa NICU. This advanced level of care provides comprehensive care to neonates born at 28 weeks gestation and weighing more than 1000 grams. Since advancing to a Level IIIa, the average census in the NICU has gone from an ADC of 2.5 to a current ADC of 9.2 and the average length of stay increased from two to eight days.
Physical Expansion
In October 2009, a consistent increase in our average daily census required the NICU to increase capacity from 10 neonates to13. This involved removing a wall, building additional infant care areas, providing a remodeled family
entrance area and adding a work station and restroom for the nurses. February 2010 saw the completion of the physical changes.
Training & Education
The advanced training and education of the NICU nursing staff began in March 2008 with existing staff completing the Perinatal Continuing Education Program in six months. This program combined a series of textbooks with written tests and was completed by several skills labs with hands-on practice for neonatal oral intubation, needle aspiration and chest tube placement, and insertion of umbilical catheters.
In addition to this program, in 2009, the NICU expanded their service line to include a Neonatal Transport Team consisting of six NICU nurses and four respiratory therapists with advanced experience and training. The additional transport training included four days of classroom education and skills labs to provide hands-on opportunities. Two of the nurses were also able to attend a neonatal transport conference, which included bedside nursing time in a Level IV NICU.
The education opportunities continued with STABLE and Cardiac STABLE classes in February and March 2010 and classes in Specialty Care for Neonates 28-32 Weeks Gestation. In addition, three of the NICU nurses were trained in placement of Peripheral Intervenous Central Catheters (PICC) in February 2010.
Increased Staff
The increased daily census has caused a need for increasing the number of nurses specialized in neonatal care. In 2008, the NICU enlarged the leadership team and added a clinical coordinator/educator to assist. In 2009, the NICU increased the nursing staff from 14 FTE’s to 20, and added a unit clerk dedicated to the NICU.
Growing Pains
Throughout the past 18 months, the RN nursing staff in the NICU has had many opportunities to gain experience in caring for compromised neonates and they have excelled. They have added a physician, six nurses, a unit clerk and clinical coordinator to their team of care givers and made them part of the NICU expanded family. The changes in staff, nursing practice and physical surroundings have not daunted their caring spirit and they continue to touch the lives of families and infants with special needs.
Tifan Picard, RN, NICU provides care to a newborn in the NICU.
Pediatric Nurse Clinician/ Virtual Pediatric UnitBillings Clinic hired a pediatric nurse clinician in January 2009 with the goal of improving care to some of our youngest patients. Christy Buffington, RN, BSN, came with a depth and breadth of pediatric knowledge and experience that drove practice change from her intial days in her new role. As her first initiative she conducted a pediatric needs assessment through direct observation. Four primary needs were identified and classes were developed to provide education to address those specific needs:
Pediatric Physical Assessment
Pain Assessment and Interventions
•
•
Fluid Maintenance Calculation
Medication Administration
Ms. Buffington conducts rounds Monday through Friday on all pediatric inpatients. During these rounds she works with the patient’s primary nurse to develop pediatric specific plans of care and reviews the patient/family education plan. Also, the rounds help to facilitate consistency of care as well as facilitating real-time learning by working side by side on any pediatric nursing procedures.
Standardizing Pediatric Care at Billings Clinic
The Pediatric Inpatient Guidelines were revised and re-titled “Pediatric Standards of Practice.” This document outlines the standards of care each pediatric inpatient can expect to receive and covers the Intensive Care Unit (ICU), designated pediatric areas, and Psychiatric Youth Treatment Unit (PYTU).
Billings Clinic is currently planning a pediatric inpatient unit to further solidify our care of children.
•
•
Christy Buffington, RN, BSNPediatric Nurse Clinician
During the past year, my knowledge of pediatric care has improved.
During the past year my confidence in careing for pediatric patients has improved.
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Very Much
Somewhat
Undecided
Not Really
Not at All
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Very Much
Somewhat
Undecided
Not Really
Not at All
10 11
Building Our Future
Nov
ice
Adv
ance
dBe
ginn
erCo
mpe
tent
**
Profi
cien
tEx
pert
New staff memberNo experience with situations in which they will be expected to performUses rules to guide actionsUnable to use discretionary judgement
Demonstrates acceptable performanceHas coped with real situations to establish recurrent meaningful situational componentsDemonstrates knowledge of & compliance with policies and procedures
Able to see their actions in terms of long- range goalsAppreciates the complexity of a task or eventAble to prioritize response based on criticality of cuesPlan is based upon considerable conscious, abstract, analytical contemplation
••
••
•
•
•
•
•••
Able to interpret an evolving situation
Able to apply experiential learning
Fluid and effortless performance begins to emerge;
no one plan is held “sacred”Best taught by use of case studies
Optimal performance is second natureNo longer relies on analytical principle to
connect understanding of the situation to an appropriate action; has an intuitive
grasp of the situationZeros in on the accurate region of the
problem without wasteful consideration of a large range of possible solutions
Perceives situations in their entirety
•
•
•
•
••
•
•
**Note: Each unit may opt to have different tracks in the competent level reflected in the various shades represented (dark to lighter purple)
Building Our Future
Novice to ExpertBillings Clinic’s Education Council members participated in a two-step process in summer 2009 to clarify structures and processes by which education is provided for nursing staff at Billings Clinic.
The first step, a full day retreat, resulted in recommendations for an education model, a model for competency validation and the creation of the Education Flow Sheet.
In the second step the education council reviewed and adopted the Novice to Expert model based on the work of Patricia Benner for staff education and development. These models are used to create common language, convey leadership expectations, spell out processes associated with orientation and education, and guide the work of unit based educators.
Billings Clinic’s ICU offers a detailed example of decentralized nursing education. ICU incorporated Benner’s Novice to Expert Model into its unit plan that employs color groups to describe staff competence. Pam Zinnecker, RN, BAN, MNEd, CCRN, Intensive Care Unit, nurse clinician, collaborated with critical care leadership and the ICU education committee to integrate use of color coding into ICU staff development groups.
Each shade group represents a staff development level validated by using detailed assessments and evaluations. ICU RN staff members progress systematically from level to level and must achieve competency consistent with the current level prior to advancing to the next, more advanced level.
All ICU nurses start in the Novice staff development level. To advance to the Advanced Beginner staff development level the nurse must complete a series of critical care classes as well as a knowledge assessment. The knowledge assessment assures the nurse has the knowledge and competence to move into the advanced beginner level.
The staff development level has two pathways leading to proficiency; medical track and the surgical track. The nurse will complete advanced education on the critical medical patient such as sepsis and cardiogenic shock. A final test will demonstrate competency. The surgical track consists of open heart orientation. The nurse will complete a class, observe open heart surgery and receive precepted training on the care of the open heart patient. Once the nurse has completed both the medical and surgical tracts they move into the proficient staff development level. Advancing from the proficient to the expert staff development level is determined by peer evaluation and completion of mandatory education.
Patients are also categorized into color groups based on American Association of Critical Care Nurses (AACN’s) synergy model. Patients are categorized based on complexity, vulnerability, resiliency and predictability. For example, the novice nurse will be assigned to a patient from the blue patient group (not complex or vulnerable, resilient and predictable). The expert nurse will care for the patient that is very complex, quite vulnerable, not resilient and not predicable.
ICU’s education plan coordinates learning activities necessary to ensure that nurses are prepared to care for complex critically ill patients. Patient assignments are made based on these skill levels or “colors.” ICU’s staff development group, education plan, evaluation, and staff assessment documents demonstrate tools and processes that contribute to the well developed ICU unit specific education plan.
Pam Zinnecker, RN, BAN, MNEd, CCRNNurse Clinician ICU
References: 1) Brenner, P. (1982). From Novice to Expert. American Journal of Nursing, 82 (3), pp. 402 407. 2) Brenner, P. & Tanner, C. (1987). Clinical Judgment: how nurses use intuition. American Journal of Nursing, 87 (1), pp. 23 31. Created 3.2010; Rev. 4.2010
ExpertProficientCompetent
AdvancedBeginner
Novice
12 13
Building Our Future
New Medical/Surgical Nurse ClinicianIn October 2008. Sherry Herbert, RN MSN, came to Billings Clinic from California. Sherry provides leadership and program development for the medical-surgical service line in the areas of professional practice, staff development, education and quality management founded on current research and evidence of best practice. Her experience is vast and varied with expertise as a nurse, clinician and educator.
Sherry has Midwest roots but has lived in Texas, Wyoming and various places in California. Her first nursing job was in a small rural hospital where her new grad orientation consisted of learning a “med nurse” role for three days and how to use a fire extinguisher in the parking lot. She remembers nurses mixing medications in a “medication room.” While the practice and process of nursing has changed from Sherry’s first experience, she expresses gratitude for the opportunity to work in a facility that required her to “do everything” – from ER to OB to urgent care. The care model was team nursing and that initial experience set the foundation for Sherry’s nursing practice.
Some of Sherry’s moves were associated with her husband’s military commitments and pursuit of a law degree and law career. She worked for four years as a staff nurse in ICU, CCU, Telemetry and the Cardiac Cath lab at Sutter Memorial Hospital in Sacramento California. Sherry’s career has also been shaped by her commission in the army nurse reserve
corps. A “best” learning opportunity associated with this was participation in the “Wounded Warrior exercise” which involved setting up MASH hospitals for training purposes.
Education and leadership have always been important aspects of nursing to Sherry. She has served in a role similar to that of a charge nurse and developed orientation and education programs for new staff. Her initial orientation experience in the hospital parking lot at her first job (as well as other, more nursing focused experiences) caused her to seek innovative ways to help new staff adapt to their roles successfully.
She finished her master’s degree in 2006 at Cal State Domingus Hills. Employment at Salinas Valley Memorial Hospital (SVMH) allowed Sherry the opportunity to do special projects, including helping nursing departments prepare for Joint Commission surveys. Sherry contributed to the education of nurses and CNAs while she worked with a highly cohesive nursing faculty at Central Wyoming College.
Sherry and her husband returned to SVMH in California at the request of her previous employer so she could fill a Clinical Nurse Educator role. After several years, the quest for a different lifestyle led them to reconsider Wyoming; and because of a chance dinner conversation - Billings, Montana. When Sherry’s online research uncovered the Billings Clinic Magnet designation with a position open in an area she loved, she looked no further.
Sherry commented that teaching nursing at the bedside in a hospital is the “best” and also most challenging thing she could do. Sherry has completed a revision of Medical-Surgical nursing standards of care and is working hard with the Pressure Ulcer Prevention team. She is a part of the Medical Surgical leadership team, the Education Council and other related task forces.
Sherry Herbert, RN, MSNMedical-surgical services
Building Our Future
Surgery Center Off and Running!
At the time, Surgery Center Director, Barb Ward, RN, said, “Things are going well! Morale is high and the teamwork has been exceptional!”
The center is patient focused. “Patients’ families really love the beautiful waiting area and find it relaxing. They also like the ease of getting in and out of the center,” Barb added. “The feature that the patients love most is our ‘Bair Paws®.’ They are disposable surgical gowns that hook up to warm air that flows into the gown. It follows them from pre-op to post-surgery. Maintaining the patient at a normal body temperature has been shown to improve healing and also makes them very comfortable.”
According to Barb, there was a learning curve for staff working in the new facility in order to become more efficient
with the work flow. Initially, nurses trained in one area to become very comfortable with the routine and care. In time, they will cross train to other areas to allow more flexibility in scheduling and improve productivity. This is consistent within the model of care for many surgery centers in the country.
Patient satisfaction continues to be high, and comments very positive. Staff satisfaction results are also high. Barb feels that the results of those scores can be attributed to the wealth of experience, knowledge and teamwork here. It really is one big family caring for our patients and their families.
The Surgery Center features state-of-the-art surgery suites where Billings Clinic physicians and care providers including Christy Gerdes, RN, Surgical Tech Karla Willman and Ophthalmologist Daniel Weaver, MD, provide surgical care for patients.
Billings Clinic’s Surgery Center opened in February 2009.
Organizationally, Billings Clinic had significant divert issues due to lack of medical-surgical beds. The movement of inpatient cancer patients to the new ICC unit has opened medical-surgical beds to accommodate those consistently high patient volumes. This organizational change also allows direct-care RNs to provide the care for which they have chosen to be trained, thus positively impacting nurse satisfaction.
Medical-Surgical Full Bed Divert
302 293
00
50
100
150
200
250
300
350
2007 2008 2009
Hou
rs
14 15
NursingQuality
& Research
Building Our Future
Optilink - Staff RunnerHaving a way to measure productivity, staffing, patient acuity and quality are vital to the work that nursing leadership, charge nurses and direct care RN’s do on a daily basis. Billings Clinic utilizes Optilink-Staff Runner and Nursing Compass to achieve these goals. These systems provide trending data influencing decision making. Nursing leadership attends weekly Value Team Meetings, sharing and reviewing lessons learned by utilizing trended data available from the systems.
Staff Runner:
Self scheduling increases staff satisfaction by giving them control over their schedules while maintaining budgetary thresholds and department staffing needs.
Electronic scheduling gives leadership the ability to monitor and manage salary budgets in an orderly and effective fashion.
Patient Classification Staffing and Scheduling (PCSS)
Allows us to assign acuity levels that have been tailored to our units using input from our direct care staff.
•
•
•
Utilizing the acuity of the patient, charge nurses can determine the true workload of their patients and assign them accordingly.
Nursing Compass
An innovative web based business intelligence product that provides nursing leadership real time decision support to drive staffing, productivity and quality performance improvements across Billings Clinic.
Snapshot Census, taken every four hours provides true workload on the unit at each time point. The average of the six snapshots provides a Blended Census or average census for the day. These data points allow leaders to think in terms of workload on the unit as opposed to midnight census.
Variance Analysis Dashboard provides leadership tools to daily track productivity allowing ability to drill down to unit level detail.
•
•
•
On-sitePresentationfromAdvisoryBoard aboutproducts
UserSummitNursingCompass - Sandy/Luattended
WeeklyCalls/beganbuildingOptilinkandNursingCompass
System Admin. Trainingattended by:
-Sandy Morse-Shelley Phelps-Sherrie Fuller-Benge-Sherri Zimmerman
Sta�Runner
Go-Live
NursingCompass
Go-Live
PCSS
Go-Live
ICC SelfScheduling
Go-Live
OptilinkUpgradeVersion 6.4
Nursing Resources, IPM, IPS, ATU Self Scheduling
Go-Live
Value Team Meetings
Optilink User Summit attended by:
-Sandy Morse-Sara Ogurek
On-Site from Nursing Compass Advisors - Adjustments/Corrections made to mapping, process for capturing �les, sending data to compass
Began capturing1 to 1 hoursWeekly Fallsand Med Errors in CompassSite
ICU SelfScheduling
Go-Live
Time Change to HR �le to capture entire previous days hours/dollars
Snap-Shot Census
2007 03/08 04/08 06/08 12/08 02/09 05/09 08/09 12/09 01/10 03/10
Timeline - Nursing Compass/Optilink
16 17
Nursing Quality & ResearchNursing Quality & Research
Focused work teams comprised of PUP Team members worked on selected aspects of the projects (policy/procedure revisions, respiratory care interventions related to ET and oxygen tubes, etc.). Ms. Herbert officially reported to the Clinical Practice Council and the Cerner Documentation Council on an as-needed basis to provide updated PUP Team information.
After the practice and documentation standards were revised and implemented, classes were provided throughout the organization. PUP Team members participated in the course instruction. Classes were scenario-based and included an interactive “improv” method for assessment and treatment of pressure ulcers.
Changes in Patient Care
Outcomes
Year 1: February 2009 - February 2010:
Hospital-acquired pressure ulcers declined by 50 percent as evidenced by the NDNQI Prevalence Study results for 2009 when compared to 2008
Quarterly studies conducted on September 15, 2009 and December 8, 2009 identified a total of eight hospital-acquired pressure ulcers. Six of the eight were located on the ears and were caused by oxygen tubes. Education was provided to the nursing staff regarding ear pressure ulcers. Pressure ulcer comparison from 2008 to 2009 is expressed below in Pressure Ulcer Comparison:
2008 ~ 46 hospital-acquired pressure ulcers (NDNQI Pressure Ulcer Prevalence data)
2009 ~ 23 hospital-acquired pressure ulcers (NDNQI Pressure Ulcer Prevalence data)
•
•
-
-
Pressure Ulcer Prevention (PUP) Team
Background
A number of factors were the impetus to develop a multidisciplinary Pressure Ulcer Prevention Team (PUP). In January 2009, Joanie Schneider, RN, BSN, staff nurse, Inpatient Surgical (IPS); Katherine Gowan, RN, BSN, staff nurse, IPS; and Karen Rogge, RN, WCC, Wound and Ostomy, shared with Sherry Herbert, RN, MSN, clinical nurse educator for the Medical-Surgical units, they felt nursing staff at Billings Clinic could improve pressure ulcer/wound care and education. They recommended a revision of the computer screens to permit more thorough documentation of wound care assessments and treatments. Ms. Herbert suggested to Lori Jens-Allran, RN, BS, director, Medical-Surgical Services, that a multi-disciplinary team be created to address pressure ulcers and wound care. As the team was being organized, CeCe Castro, RN, IPM manager, conducted informal chart reviews. She concluded that current documentation was inconsistent and the computer screens did not permit documentation that demonstrated the standard of care was being followed.
The multidisciplinary team included representation from all clinical units and entry points. Bedside clinicians included registered nurses, certified nursing assistants, and dieticians.
In February 2009, Ms. Castro agreed to chair the PUP Team and the journey began. An observational audit was done, brainstorming took place and the following purpose and goals were established.
Purpose
To develop a comprehensive skin and wound care program at Billings Clinic
Goals
Eliminate hospital-acquired pressure ulcers
Improve the electronic skin/wound documentation screens for all clinicians
Revise skin and wound policies and include quick reference tables
Implement the Braden Q Risk Assessment for pediatric patients
Develop unit wound teams to provide advanced wound care and expert consulting services
Develop an educational plan that integrates with Billings Clinic credentialing process and the novice to expert framework for all bedside clinicians
•
•
•
•
•
•
Analyze effectiveness of current skin/wound care products
Develop a Community Liaison Team to improve wound care when patients transfer
Develop data collection tools
Develop and implement organizational educational initiatives (bedside clinicians)
Replace devices causing pressure ulcers (oxygen tubing, ET holders, etc.) and/or develop additional preventive strategies for eliminating device-related pressure ulcers
Develop and implement nutrition screening criteria and automatic referrals for dietary consults
Analyze effectiveness of current overloading devices and make recommendations for replacements as appropriate
Provide direct administration and oversight of the quarterly NDNQI Pressure Ulcer Prevalence Study
Analyze the wound consultation process; if not meeting current patient needs, collect and analyze supporting data and make recommendations
Develop and provide advanced wound care education for providers (medical staff and licensed independent providers)
The team officially began in February 2009. They met weekly for approximately six months and continue to meet monthly at this time.
Using the Contextualist Model, Ms. Herbert, Ms. Schneider, Mr. Fisher and Ms. Rogge conducted informal observation studies every Friday morning for a month to better understand the variables and complexity of skin-wound assessments/treatments, medical record documentation, staff education and patient/support system education. They observed bedside clinicians performing head-to-toe skin assessments, documenting findings into the electronic medical record, and implementing preventive strategies (skin care products, repositioning, redistribution devices, specialty beds, etc.) as they related to the Braden Risk Score.
Simultaneously, as part of the AHRQ/Boston Study Grant (see page 24) whose main purpose is to develop a pressure ulcer prevention tool kit, Billings Clinic participated in completing the “Pieper Pressure Ulcer Knowledge Report.”
Based on observation study results, the team developed a project timeline and plan. The timeline was divided into several phases over a three to five year time frame. Analysis was conducted and decisions were made by the PUP Team.
•
•
•
•
•
•
•
•
•
•
AssessReadiness
ManageChange
ImplementPractices Best
Practices
MeasureSustain
Tools
18 19
Nursing Quality & ResearchNursing Quality & Research
Fall Prevention at Billings Clinic The Patient Safety committee at Billings Clinic, led by Nancy Iversen, RN, BSN, CIC, identified an opportunity for improvement in patient safety based on the fact that patient falls in the organization are above the national average.
After reviewing the literature, the team concluded that the screening tool in use at Billings Clinic at that time actually identified the majority of our patients at an increased risk for falling and did not help us focus on those at the greatest risk. The team agreed that we needed to design a new patient fall assessment tool, enhance our interventions, and provide additional staff education to promote success with the new process. Billings Clinic chose to adopt the Hendrich II model.
Steps that were included in the implementation process included:
Design and development of electronic fall assessment tool to be completed in the Electronic Medical Record (EMR) by the RN each shift.
Developing standard interventions for each patient fall risk category of low, moderate, and high. Basic interventions for the patients in the low risk category were built upon as the fall risk increased.
Developed standard signs to identify patients at a risk for falling called “Falling Star”.
Developed and posted signs in each patient room called “Call – Don’t Fall” to engage patient and family education and cooperation.
Recommendation to include fall risk status, risk factors, and interventions in place to prevent patient falls in hand off report.
Implementation of post fall huddles to occur as soon as possible after a patient fall to identify cause of fall and how to prevent future similar occurrences.
Switching to yellow arm bands and yellow slippers for patients at risk to fall to align with national recommendations on arm band colors.
Nursing staff education on new assessment tools, interventions, and documentation tools.
Education with ancillary departments in the organization including Rehabilitation Services, Respiratory Therapy, Dietary Services, and Environmental Services to help keep our patients safe.
•
•
•
•
•
•
•
•
•
The new Fall Prevention Program was launched in May, 2008. We have experienced an overall decrease in the number of falls in the organization; however, we have not been able to consistently sustain our progress over the course of the past 18 months as demonstrated in the following chart.
Benefits that we have achieved as a result of this initiative include:
Greater staff awareness related to patient safety
Purchasing and implementing technical solutions to prevent patient falls including chair alarms and bed alarms
Common language around patient safety with the “Call – Don’t Fall” campaign
•
•
•
Changes in Work Environment
Outcomes
Revised the skin and wound practice standards to include related policies and procedures to ensure standardization across the organization
Revised the electronic medical record to better support practice standards and clinician work flow
Implemented the Braden Q Risk Assessment tool for pediatric patients
Developed quick reference charting guidelines for clinicians as they document their assessments. These were embedded into the computer screens for easy access
Educated staff (including clinical staff throughout the organization) on the following:
Assessment of skin and pressure ulcers
Updated practice and documentation standards
Use of specialty beds and equipment in-service
Use of new skin and wound product lines and new oxygen tubing
•
•
•
•
•
-
-
-
-
Trialed pressure ulcer incidence data collection process and data collection tool
Developed and implemented documentation audit tools following the revised computer screens roll out
Evaluated effectiveness of current nutrition support screening criteria (concluded current screening by dieticians is effective in identifying at risk patients)
Evaluated different oxygen tubes and padding devices; purchased most appropriate devices based upon trial results
Implemented the following interventions to address ear pressure ulcers:
Purchased new oxygen tubing with pre-attached foam protectors and softer nasal cannula
Implemented the following related practice standards:
Apply Cavilon “No Sting” Barrier to the outer ear of patients with oxygen tubing
Reposition oxygen tubing every two hours for chronic O2 users and/or high risk patients (i.e., Braden score of 18 or less)
Educated staff on practice changes
•
•
•
•
•
-
-
•
•
-
Pressure Ulcer Comparison 2008-2009
7
11
8
20
8 75
3
0
5
10
15
20
25
Q1 Q2 Q3 Q4
# H
ospi
tal A
cqui
red
Pres
ure
Ulc
ers
2008 2009
20 21
Nursing Quality & Research
A control chart was used to study LOS. Data were plotted in time-order with the central (light purple) line representing the average. The team concluded that because the process variation was unpredictable, it was out of control and affected by special causes of variation. This validated their assumptions regarding LOS variation and the project commenced.
Communication of scheduled discharge appointment times has led to decreased LOS and divert hours. It has also improved patient/family satisfaction as well as staff/physician teamwork.
Nursing Quality & Research
Reduction in Patient Length of Stay ProjectThis project was the result of a strategic initiative to reduce the organizational length of stay (LOS).
The objective of this project was to reduce LOS by .25 days and reduce the number of hours on divert by 70 percent by end of fiscal year, June 30, 2009. The focus of the strategy is as follows:
As an integrated health care system with employed physicians, the organization needed to maximize capacity to meet the demands of the patients that required admittance by Billings Clinic physicians
Decrease divert hours to maintain our level II trauma status
Implement targeted discharge times for patients on medical-surgical units
Consistency in patient education
The surgical length of stay project began in spring 2008 with a multidisciplinary team that included leadership, staff nurses, care management, and decision support from the following departments:
Patient Financial Services
Physicians
Care Management
Environmental Services
Information Systems
Supply Chain Operations
•
•
•
•
•
•
•
•
•
•
A two-day LOS project kick-off was held the end of July. More than 40 staff and physicians representing multiple departments that impact LOS attended the event. The project champion, Lu Byrd, RN, MN, CNO, “called to action” this very important strategic initiative.
Specifically, the targeted discharge project team identified that inconsistencies in the discharge process and the time required to organize and complete all pre-discharge activities was identified as a key barrier to timely patient discharge.
The discovery process led to the initiation of a scheduled discharge time in February 2009. Multiple disciplines organize discharge activities to be completed by the anticipated
prescheduled discharge time.
One of the secondary drivers for evaluating LOS was an issue with capacity and the divert hours that impacted the organization’s ability to provide care to patients who identified the organization as their primary care base. Divert hours were tracked prior to the work of the LOS team and also for an extended
period of time as the organization focused on this efficiency issue. The above initiatives have led to an overall decrease in length of stay. In fiscal year 2009, there has been a reduction of .435 days and a 430 percent reduction in divert hours from the 2008 baseline and provided a financial benefit in FY2009. Reduction in LOS and divert hours has created a gain of 14 beds. Patients desiring care at Billings Clinic are able to be admitted and not diverted. Improvement in patient and family satisfaction along with improvement in teamwork among physicians and staff occurs when targeted discharge dates and times are scheduled and well communicated.
Pre-Admission Testing Lab
Pharmacy
Respiratory Therapy
Physical Therapy
Radiology
Dietitians/ Diabetes Educators
•
•
•
•
•
•
Highlights of the event included admit to discharge simulation, process mapping, brainstorming, and establishing the LOS Steering Committee.
Medical Surgical Length of Stay (LOS)
Inpatient Surgical Length of Stay (LOS)
LOSPatient Flow Management
PhysicianPA/NP
CareManagement
EVS
InformationSystems
CodingMSDRG Coders
ED
TherapyNursesDischarge Nurse
DiabetesEducators
AncillaryLab
RadiologyPulmonology Home Oxygen
Dietitians
Pharmacy
Aspen
PAT LabSurgery
Supply ChainOperations
AODObservation
Unit
Patient AccountsAdmitting
Financial CounselorsBed Board
22 23
Nursing Quality & Research
The toolkit aims to address the following six dimensions of clinical care and organizational context:
Systems to ensure pressure ulcer best practices
Measurement of pressure ulcer rates
Unit culture and operations
Readiness for change
Organizational culture of improvement
Management support
Key interventions and tasks for this project included:
Analyzing the current state of pressure ulcer prevention practice at Billings Clinic
Identifying the bundle of prevention practices for a redesigned system
Assigning roles and responsibilities for implementing the redesigned pressure ulcer prevention practices
Putting the bundle into practice
Monitoring pressure ulcer rates and practices
Sustaining the redesigned prevention practices
An informal survey demonstrated action plan results and was conducted by the ICU research team. Pre and post implementation data are demonstrated.
RN Opinions Regarding Pressure Ulcer Prevention
Statements Included in Survey
I do not need to concern myself with pressure ulcer prevention.
Most pressure ulcers can not be avoided.
I am not interested in pressure ulcer prevention.
My clinical judgment is better than any assessment tool
Pressure ulcer prevention is a relatively low priority for me.
•
•
•
•
•
•
•
•
•
•
•
•
1.
2.
3.
4.
5.
Statements Included in Survey
I know the difference between a stage II and stage III pressure ulcer.
I always know the preventative measures I need to implement
I am comfortable choosing skin care products for my patients with pressure ulcers.
Pressure ulcer prevalence at Billings Clinic is reported using the National Database for Nursing Quality Indicators (NDNQI).
Billings Clinic Hospital Acquired Pressure Ulcers
Working with these experts gave Billings Clinic the opportunity to participate in a national research project representing our patient population. This valuable experience allowed Billings Clinic nurses to help develop a toolkit that may impact patient care on a national level.
1.
2.
3.
Nursing Quality & Research
Billings Clinic Participates in the Boston University Pressure Ulcer Research ProjectIn October 2008, Billings Clinic was invited to participate in a research project led by Boston University Medical Center. The Agency for Healthcare Research and Quality (AHRQ) funded the project. By participating in this project, Billings Clinic collaborated with:
Dan Berlowitz, MD - Principal investigator and professor of health policy and management at Boston University School of Public Health, as well as director of the Center for Health Quality, Outcomes, and Economic Research. In the long term care setting he supports assessment of nursing home care through risk-adjusted outcomes calculated from administrative databases. Modeling from pressure ulcer development, he has demonstrated how these data may address policy-relevant issues. He received a MD from the Albert Einstein College of Medicine and a MPH from Boston University.
Carol VanDeusen Lukas, EdD - Co-principal investigator and faculty member of the Health Services Department at the Boston University School of Public Health.
Elizabeth Ayello, RN, PhD, ACNS BC, CWON, ETN, MAPWCA, FAAN - Project consultant, wound and skin expert, faculty member at Excelsior College School of Nursing in Albany, New York, and senior advisor at the John A. Hartford Institute for Geriatric Nursing in New York. She is also the editor for the World Council of Enterostomal Therapists (WCET) Journal. Dr. Ayello’s most recent publication, Pocket Guide to Pressure Ulcers, was provided to all staff at Billings Clinic.
Karen Zulkowski, RN, DNS, CWS - Project consultant, associate professor at Montana State University-Bozeman, a member of the National Pressure Ulcer Advisory Panel (NPUAP) board of directors, and an American Academy of Wound Management (AAWM) certified wound care specialist. She has conducted numerous research projects on pressure ulcer treatment and prevention.
The research team was dedicated to partnering with hospitals committed to improving pressure ulcer preventative care. With a pressure ulcer rate of five percent, Billings Clinic met the criteria to participate in the project and agreed to commit to and pay staff to form a multidisciplinary quality improvement team.
•
•
•
•
In the initial stages of this project, 187 Billings Clinic nurses from inpatient settings participated in the Piper Pressure Ulcer Knowledge Survey. Knowledge gaps from the survey were shared with our internal Pressure Ulcer Prevention (PUP) Team; the multidisciplinary quality improvement team for the project.
The primary goals of the project were to:
Accelerate change and transformation in organizations and networks
Review successful approaches to prevention of pressure ulcers in hospitals
Work with partners to establish hospital quality improvement teams and tool workgroups
Develop and pilot test a toolkit of pressure ulcer prevention practices through the adoption or adaptation of existing instruments and development of new instruments
Implement a quality improvement project using pressure ulcer prevention tools in partner hospitals
Assess lessons learned during the quality improvement project through monitoring staff use of the tools, observing changes in prevention practices, and determining changes in pressure ulcer rates
Incorporate lessons into a pressure ulcer prevention manual, the major project product
Pam Zinnecker, RN, BAN, MNEd, CCRN, the Billings Clinic project lead, worked with the project experts and the PUP Team to pilot tools aimed at creating a pressure ulcer prevention practice. In April 2009, she met with the Nursing Research Council (NRC) to validate the following project expectations:
Patient care providers, especially nurses, are more aware of pressure ulcer prevention
Patient care providers understand the Braden Scale for determining patients at risk for pressure ulcer development
Patient care providers are more comfortable documenting pressure ulcers
Patient care providers are implementing prevention measures more often
Patient care providers understand and use the products chosen by the PUP Team with increasing comfort
•
•
•
•
•
•
•
•
•
•
•
•
RN Survey Regarding Pressure Ulcer Prevention
0%
20%
40%
60%
80%
100%
1 2 3 4 5
% o
f Nur
ses
June-09 June-10
RN Survey Regarding Pressure Ulcers
0%
20%
40%
60%
80%
100%
120%
321
% o
f Nur
ses
June-09 June-10
Billings Clinic Hospital Acquired Pressure Ulcers NDNQI National Database
0
5
10
15
20
25
3Q 08 4Q 08 1Q 09 2Q 09 3Q 09 4Q 09 1Q 10 2Q 10
# of
Pre
ssur
e U
lcer
s
24 25
Nursing Quality & Research
Studies show that a 6 mm Hg reduction in blood pressure could potentially reduce cerebrovascular morbidity and mortality by 42 percent, coronary artery disease by 14 percent, and heart failure by 50 percent. If successful, this research study could impact both regional and national health care outcomes including cost if implemented in other health care organizations. In 2008, Billings Clinic saw 871,281 outpatient clinic visits; of these, a total of 10,896 primary care visits resulted in the identification of appropriate candidates for this study. Thirty percent of outpatient visits were coded with a diagnosis of HTN.
Methods
A hypertension project steering committee and task force were formed, with members from leadership, information technology, and CTR staff. The Hypertension Project Steering Committee supervised this project. The Hypertension Project Task Force was created to ensure successful implementation of the project. The project was first implemented with the Internal Medicine West staff, while planning to spread to other Billings Clinic departments the following year.
The three major components of this project included:
Provider-targeted
Nurse-targeted
Patient-targeted
The first program component involved building provider consensus regarding best practices in managing HTN. Clinical hypertension best practice and standardization of blood pressure measurement were adopted.
The second program component was nurse-targeted. If providers began changing patients’ blood pressure medication regimens, blood pressure measurements taken by nurses had to be accurate and reliable. Observation by Ms. Holloway revealed that current nurse practices varied by education and experience. As a result, clinic nurses adopted an updated, comprehensive protocol for blood pressure measurement in the clinic environment. Clinic nurses, led by Ms. Waleri, Ms. Caton, and Ms. Holloway, created this protocol in collaboration with nursing professional development staff, led by Ms. Loper.
The third project component developed a Patient Hypertension Report Card. This report card includes recent blood pressure measurements, patient medications and weight, as well as diet and exercise recommendations.
•
•
•
The 16-month project established Billings Clinic’s best practice guidelines and education protocols, built provider and nursing consensus and developed the Patient Hypertension Report Card in the first six months (September 2008 - February 2009). Information dissemination throughout the system and implementation occurred in months seven through twelve (March 2009 - August 2009). Program evaluation continued in months 12-16 (August 2009 - December 2009), including continuing staff education and monitoring office process changes.
Positive Deviance
Initially, the project began with the traditional top-down method. The task force planned to teach all involved correct principles, hoping for compliance. However, the task force became aware of a behavioral change technique called Positive Deviance (PD) early in the study. PD has proved effective in changing group behavior in multiple settings and was recently used in health care.
Initially, the task force met with providers from Billings Clinic West to assess HTN management and gain their point of view. Providers asked for more detailed data from all Billings Clinic’s primary care branch locations by provider. They also expressed concern that nurses were not using correct techniques to measure blood pressure. Some providers would retake blood pressure measurements due to mistrust of a nurse’s technique.
The task force then met with nursing staff separately. Nurses identified several issues, including:
The pressure from providers to spend as little time as possible rooming patients was a barrier to accurate blood pressure measurement
Exam rooms did not have adequate blood pressure equipment
Blood pressure measurement technique was not consistent among staff
After bringing together providers and nurses, the task force discussed current blood pressure processes and techniques. This process was led by Ms. Kersten. Through the PD process, barriers were recognized and solutions identified, leading to behavioral changes in practices. The Patient Hypertension Report Card educated patients about hypertension risk factors and set goals to control hypertension, and was developed in collaboration with the Information Services technical support staff. A patient education packet further educated patients regarding this disease. During February 2009 – August 2009, processes were implemented and outcome data were collected.
•
•
•
Nursing Quality & Research
Creating Best Practices in Managing Hypertension Education and Health Information TechnologyThe completed nursing study Creating Best Practices in Managing Hypertension Education and Health Information Technology, conducted by principal investigator Valerie (Kent) Caton, RN, MN, FNP-C, CTR is one example of nursing research at Billings Clinic. The project developed and expanded nursing research to the outpatient primary care clinic departments. It also established nurses as principal investigators in the Center for Clinical and Translational Research (CTR), which primarily uses physicians and PhDs to fill this role in its health services research studies.
The study was conducted at Billings Clinic West, which offers a full range of primary care services, with the Internal Medicine Department as the focus. The department has four internal medicine physicians and one non-physician provider. The key stakeholders of the interdisciplinary team project include:
Valerie Caton, RN, MN, FNP-C, principal investigator, CTR
Eric Saberhagen, MD, Internal Medicine, physician champion
Barbara Holloway, RN, BSN, CDE, study nurse coordinator
Diane Kersten, MSW, LCSW, Positive Deviance coordinator, Geriatric Services
Norma Waleri, LPN, on-site coordinator, Billings Clinic West
Elizabeth Ciemins, PhD, MPH, director, Grant Management
Internal Medicine physicians, the non-physician provider, nursing staff and their patients with hypertension were participants in the study.
Ms. Caton developed the research proposal and sought funding through the Association for Advanced Nurse Practitioners (AANP) Foundation Grant Project. The project received $4,000 in 2008, allowing for data collection at Billings Clinic West.
Purpose and Background
Hypertension (HTN) is a major contributing factor for heart disease, the number one cause of mortality in the United States. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 8 Guidelines contain objective control measures and recommendations for providers helping patients achieve HTN control, yet many people who obtain regular health care still have blood pressures considered uncontrolled.
•
•
•
•
•
•
Project Objective and Specific Aims
The project aimed to improve the use of Best Practices in Managing Hypertension among Billings Clinic clinicians. Provider level measurable outcomes include behavior changes surrounding hypertension among clinic providers. Desired provider behaviors include documenting blood pressure as controlled or uncontrolled. If uncontrolled, the provider would take action to correct this or document why such action was not taken.
Patient outcomes measured for this project include the percentage of patients receiving an educational, hypertension-specific, patient report card as well as the percentage of patients with controlled blood pressure (controlled as defined in the guidelines).
Epidemiology of Hypertension
According to the National Health and Nutrition Examination Survey (NHANES), nearly one third of the US population has hypertension. Data from epidemiological studies show high blood pressure is a risk factor for many serious health conditions, most notably cardiovascular disease (i.e., coronary artery disease and congestive heart failure), cerebrovascular disease/stroke, and kidney failure. Associated with high mortality, cardiovascular disease is the leading cause of death throughout the world. For every 20 mm Hg systolic or 10 mm Hg diastolic increase in blood pressure, there is a doubling of mortality from both ischemic heart disease and stroke.
Significance
The national health care system must change in order to provide evidence-based care to an aging population with complex, chronic medical problems. Alternate health care models need to be developed that can help clinicians, staff, and patients improve the quality and safety of health care in the United States. While health information technology seems the logical choice to transform health care in the ambulatory setting, little is known about its value in chronic disease management.
Demographics of Hypertension Patients(n=10,896)
Age Group Percentage Gender Percentage
21-39 3.6% Female 59.5%
40-64 40.0% Male 40.5%
65-75 26.2%
76+ 30.1%
26 27
Nursing Quality & Research
The Patient Hypertension Report Card has been developed and is being implemented. To stimulate discussion, posters in exam rooms ask, “How is your BP today?” One provider noted recently her patients are more aware of their HTN due to these efforts. When she enters the room, they are ready with their sleeves rolled up and both feet on the floor.
Significance of Results
The demonstrated changes in provider and nurse behaviors resulting from the intervention have significant implications for HTN management at Billings Clinic. The PD intervention, which took a bottom-up approach to behavior change, proved successful in changing behaviors of providers and nurses caring for patients with hypertension.
Following the intervention, providers significantly increased their recognition of and actions toward uncontrolled blood pressure when compared to two control clinics. More patients with high blood pressure were recognized and treated appropriately, improving the quality of care provided to patients with hypertension. Therefore, providers can more successfully manage patients with this chronic condition. Based on the success of the pilot clinic site, dissemination of the intervention to other primary care clinics at Billings Clinic will follow.
The intervention also changed nurse behaviors. Nurses were trained to take more accurate blood pressure measurements and document arm circumference and cuff size. These areas saw significant improvements, resulting in better patient care; patients are more likely to have an accurate blood pressure taken with the appropriate cuff.
Finally, this intervention resulted in increased interaction between providers and nurses. Though some providers had retaken blood pressures on patients for 20 years, they began to trust nurses’ actions after witnessing their accurate blood pressure measurements. This change impacted clinical practice by improving workflow and reducing redundant practices. Ultimately, as the clinic became more efficient and practices more accurate, the quality of patient care improved.
Discussion
Billings Clinic has learned that change can occur without mandating provider decisions regarding medications and that providers and nurses may overestimate their level of communication. The keys to successful change are found within the health care community itself and, in this case,
within the community environment of the West End Internal Medicine Clinic. PD is a useful tool in changing group behaviors and can be implemented in the health care setting. Billings Clinic plans to continue studying this behavior change method and tracking improvements in blood pressure results in the outpatient setting.
The PD intervention introduced the useful ability of tracking behavioral changes regarding hypertension control. Behavioral changes usually occur in advance of outcome results, and Billings Clinic believes hypertension control results will continue to improve in future months. Finally, evidence has shown PD results in sustained change, an improvement over traditional top-down methods where change is less sustainable.
Study Limitations
PD cannot be used in a short time span because change must come from the community itself. This limitation makes assigning time-sensitive elements to be finished or created difficult. The community decides which elements are problematic and the measures to be taken, whereas management determines action in a traditional top-down approach.
Another limitation to the study was determining which provider should be recorded as the primary care provider in the system. As a result, this project changed the way Billings Clinic provides primary care. As a system, it altered how data collection paired the primary care provider and patient, as well as how and where the information was stored. A third limitation was the lack of use of comparison populations, which will be included during the next four months of tracking data.
Future Directions
The blood pressure protocol and patient education tools have been integrated throughout the Department of Internal Medicine and the Department of Family Practice as of April 30, 2010. In May 2010, Professional Development embraced the new blood pressure protocol, educating all new clinic nurses on the technique during orientation. Professional Development is distributing patient education packets containing study tools to all Billings Clinic departments upon request for blood pressure management. In addition, initial discussions are in process to replicate this project in the inpatient setting, using the PD model. Study findings will be shared at Billings Clinic’s Nursing Grand Rounds and at Provider Grand Rounds this fall.
Nursing Quality & Research
Outcomes
Ms. Ciemins analyzed data and documented outcomes for this project.
The PD intervention resulted in:
Significant increase in provider recognition of uncontrolled blood pressure in patients diagnosed with hypertension
•
43.3 percent increase in intervention group compared to three percent
31 percent decreases among controls (p=0.009)
Intervention provider action taken on uncontrolled blood pressure also increased
39 percent increase intervention vs. 39 percent
13 percent decreases among controls (p=0.085)
Nursing behavior changed over the course of the project, from 0.4 percent recording cuff size and none documenting arm circumference at the beginning of the study to 50 percent recording cuff size and 69 percent documenting arm circumference at patient visits (p > .0001).
-
-
•
-
-
Proportion of Patients w/ Controlled Blood Pressure Uncomplicated (< 140/90) vs. Complicated (< 130/80)
0%
20%
40%
60%
80%
Dec 08/Jan 09 Feb/Mar 09 Apr/May 09 Jun/Jul 09 Aug/Sept 09
% o
f Pat
ient
s
Uncomplicated (n = 346-465) Complicated (n = 159-241)
p=.003
Provider Recognition of Uncontrolled Blood Pressure n = 931 Patient Visits
0
0.2
0.4
0.6
0.8
1
4Q 08 1Q 09 2Q 09 3Q 09Es
timat
ed P
roba
bilit
y
of P
rovi
der
Rec
ogni
tion
Control Group 1 Control Group 2 Intervention Group
p = 0.009
Provider Action on Uncontrolled Blood Pressure n = 931 Patient Visits
0
0.2
0.4
0.6
0.8
1
4Q 08 1Q 09 2Q 09 3Q 09
Estim
ated
Pro
babi
lity
of P
rovi
der
Act
ion
Control Group 1 Control Group 2 Intervention Group
p = 0.085
Changes in Nurse Documentation Pre/Post Intervention
0.40% 0.00%
69%
50%
0.00%
20.00%
40.00%
60.00%
80.00%
Cuff Size Documentation (p > .0001) (n = 1,143)
Arm Circumference Documentation (p > .0001) (n = 397)
% C
harts
Doc
umen
ted
Pre Post
Percent Controlled Hypertension OutcomesReporting Period: Dec. 1, 2008 – Jan. 31, 2009
Diabetes Mellitus
Chronic Kidney Disease
% Controlled Hypertension
Uncomplicated HTN 420
Outpatient Visits
No No 57.9%
Complicated HTN 220
Outpatient Visits
Yes Yes 38.9%
Percent Controlled Hypertension OutcomesReporting Period: Aug. 1, 2009 – Sept. 30, 2009
Diabetes Mellitus
Chronic Kidney Disease
% Controlled Hypertension
Uncomplicated HTN 476
Outpatient Visits
No No 61.1%
Complicated HTN 181
Outpatient Visits
Yes Yes 45.3%
28 29
Caring is Contagious
Family Medicine - Billings Clinic Red LodgeDr. Robert Cole refers to the importance of patients providing us, as clinicians, “a moral occasion,” He reminds us that each patient encounter is a “measure of our moral life as it is lived moment to moment,” Each patient encounter shapes who I am, how I think about the world, my family, and my life values and goals. My life is transforming and evolving as I open each new door of my family practice.
Growing up as the daughter of a family physician I thought I knew what it meant to be a part of a “family practice.” Having married a man who chose a career in family practice, I gained deeper insight into what I thought it meant to be a part of life in family medicine. However, until I began my own career as a family nurse practitioner two years ago, I did not fully understand the depths and impact we have into the lives of families. I once thought that the life of a family practitioner was a life of fame and fortune. Everyone in the community knows you and looks up to you. They seek your attention and call you to meet their needs when they are most vulnerable. They confide in you as if you are their spouse or best friend.
I did not only think that the fame and fortune were glamorous, but also took pride in the fact that my father and husband were giving selfless days and nights helping and comforting people. I am still so proud when a community member comes up to me and thanks me for giving their family my husband’s time because he saved their loved one from a heart attack. However, with this honor, comes your own sacrifice; with this privilege comes the heartache of certain kinds of knowledge.
The intimate aspects of relationships of family practice hold a dichotomy of feelings. You see patients at their worst of times and their best of times. Families welcome and entrust us with their life and family life matters. “I am moored to my patients’ predicament, their fleshed-in lives, and the unflinching fact that we are interchangeable. Commoners all. Located by the real things we live by,” (Loxterkamp, 1999 In Coles and Testa, p. 322).
In the past two years practicing in a rural small town my utopian views of the occupation have broadened and changed. It is a difficult, challenging and emotional job. It is not a 9-5 job, but a career lifestyle. Loxterkamp (1998) asks, “Do we care about our patients, get mixed up in their feelings, or offer them only a detached and sympathetic rendering of our clinical skill?” I respond: there is a balance. Family practice is a family of intertwining relationships within the community.
Patient experiences within my small town family practice shape who I am. These relationships have grown to become what is the larger sense of community, a family. As, Dr. David Loxterkamp writes, “The purpose of community is to remind us who we are.” (Coles and Testa, p. 321) Perhaps it is larger than that. The purpose of community is to remind us not only who we are, but what we are.
Family Practice
It is helping a friend through a miscarriage, and telling a young couple they are expecting.
It is guiding a neighbor through their addictions, and celebrating two years of sobriety with a mother from playgroup.
It is breaking the news to a mother about her teenage son’s death from a car accident, then performing a sports physical on his best friend the next day.
It is conducting an exam on a co-worker’s friend who had been raped, and then guiding her through the emotional healing process.
It is mending a broken arm, and encouraging a child to say their ABCs during their well child exam.
It is diagnosing a young mother with breast cancer, and cheering her through her year of recovery.
It is helping a family you sit next to in church through hospice with their mother, and remembering her at the community celebration of life.
Family practice is listening to and learning from your patients.
It is seeing people at their worst of times, yet hearing their best life stories.
Family practice is community.
Family practice is family.
•
•
•
•
•
•
•
•
•
•
•
Erin Oley, FNPFamily MedicineBillings Clinic Red Lodge
Caringis
Contagious
30 31
Caring is Contagious
Day 3
The “work” of our group will be in the area of Children’s Health Initiatives (CHI). This means our group will go to schools and community centers to do preventative care and documentation of general health of the children. Over the next four days we will see more than 1,100 children! Our purpose is to provide dental education and teeth varnishing, perform eye screening, obtain hematocrits, do height-weight and malnutrition assessments, and provide children with vitamins and anti-parasite medication. This afternoon we do our first “CHI” and see 100 kids. Many mothers have walked for two hours carrying their children to see us.
Day 4
It is Sunday, so we walk into town and attend church. Mass begins when the priest gets there, which can be anywhere from an hour to five hours after the appointed time. He too must travel the rough roads between villages, where flat tires and broken axles are a normal occurance. The church is very poor and there are none of the usual furnishings you see in a Catholic Church…only rough wooden benches (we kneel on the dirt floor), and a small cross in front decorated with a few flowers. We are humbled and overcome by the experience. There are many of us who are fighting back tears….there would be many more to come.
Day 5
We are up at 5:30 am to prepare to go to a school in Juinta Laca. We will walk to this school, over two miles away on a very rough, rocky, and at times steep road. It is well over 100 degrees. We must always have water with us….that is a constant. The children are dressed in blue and white uniforms. We learn that some families are so poor they can only afford one uniform, and they may send their children one at a time in “that uniform.” Shoes are stuffed with paper, and pants and skirts rolled to “fit”. The children are anxious to participate in the screening (except for the finger poking), and are very forgiving of the poor Spanish we attempt to speak. One little boy was so proud of his “school supplies” and wanted to show us…he had a pencil that was about three inches long and a small broken piece of a ruler that measured maybe four inches…he was on top of the world. We spend seven hours at the school, the children wait that long to go through each station…they do not eat except for the thin porridge they had in the morning, made in large black pots over an open fire. We walk back exhausted.
Day 6
Today I will drive to another clinic (even more remote) with a Concepcion staff member and a nursing student. I am heading to Santa Lucia, which is a clinic that provides birth care to women. My goal is to teach a neonatal resuscitation class to the local staff. I have very ambivalent feelings about teaching…not because I don’t like to teach, I LOVE to teach, and have been teaching this particular program for over 20 years. As I said I do not speak Spanish, and I am hoping that I can teach with some enthusiasm and passion, using my language notes. The road is very bumpy, and in fact there is no road in places. We are now 10 minutes from El Salvador. The MSU student who is with me helps me to set up for the class—we have 12 participants! I am fortunate that the staff physician is bilingual, and he has offered to translate for me. Whew! The class goes very well, and they ask me to stay longer. I am so glad I was able teach something that they can use right away, and that will be beneficial to them every day. As I am teaching I look out the window and am struck by the familiarity of what I am teaching in this completely foreign environment. How great is it to be a nurse? What opportunities we have every day to impact lives… all over the world.
Terry Sauer, BSN, RNC, cares for school children in Honduras.
Caring is Contagious
An International Nursing Experience“A door suddenly opened, and I flew through ~ with my heart pounding and my palms sweating.”
I first learned of a group of students and faculty from Montana State University (my alma mater) exactly three weeks before I found myself sitting on a plane, headed to San Pedro Sula, Honduras. The group I would be joining is an organization called “Shoulder to Shoulder,” (S2S) whose mission it is to provide care to women and children, in the poorest part of rural Honduras. Given my background in NICU and Pediatrics, in addition to my lifelong ambition to “give back,” using the skills of a profession that has given me so much, was all the impetus I needed to take the leap!
I had three requirements for a global experience, it must:
include care of women and children
be well organized, with “hands on” opportunities
be less than two weeks in length
S2S fit every criteria! It is a wonderful organization, with a focus on providing preventative care for women and children. I couldn’t have had a better first time experience!
“Partnering” with MSU: The MSU-Billings campus is within the “medical corridor” comprising two hospitals. Billings Clinic partners with the MSU School of Nursing in providing clinical rotations and experiences for nursing students. The School of Nursing desired to partner in a global way, with one of the hospitals. Part of my reason for going, was to see how this could potentially work in the future with the Women’s and Children’s service line at Billings Clinic. The MSU group (one faculty and three nursing students) and myself, left Billings, March 10, 2010 and returned March 21…. forever changed.
Honduras
One of the poorest countries in the western hemisphere
More than 50 percent of the population live in extreme poverty
Average income: $3 per day
Less than 15 percent of the population have access to clean water
Only 3 percent of the population is age 65 or older
Access to health care in rural areas is difficult (they must walk long distances on non existent roads in, at times, extreme heat ~ 110 118 degrees)
1.
2.
3.
•
•
•
•
•
•
Day 1
We arrive at the airport (where the electricity has just gone out…again. I learned this was a regular experience in Honduras). We now wait in complete darkness, in rising temperatures. Eventually the lights come on and we are out of customs and we meet the S2S program director. We all get our supplies in the Rubbermaid® tubs we were instructed to use. One of my three tubs was entirely full of much needed antibiotics, that I was able to purchase at cost from Billings Clinic. We have joined the group from Kansas University School of Nursing –so we are 30 in total. We get our backpacks and get on THE BUS. Our destination is Concepcion. The sign in the front of the bus warns passengers not to vomit on the floor, needless to say there is no air conditioning and the heat is stifling. We are told it is 112 degrees. The bus would take us six hours on very rough and windy roads into the mountains, with an overnight in a small town, and then five more hours the next day would get us to Concepcion.
Day 2
We arrive at the clinic where there are sleeping quarters and an eating hall. We unpack supplies and learn what we will be doing for the next 10 days. Our “sleeping quarters” consist of two bare rooms with a porch. We sleep in nets or “bug huts” which zip up entirely. We never-never go without shoes….there are scorpions, tarantulas, lizards, and roaming dogs. It is very hot. There is a shower which trickles cold water only…and we are to use that sparingly. Toilet paper goes into a garbage can, and never the toilet. The first night is difficult.
Terry Sauer, BSN, RNC, performs an evaluation of this young girl’s oral hygiene.
32 33
Caring is Contagious
Day 7
Today we walk to a community center where families have gathered who would like water filters. We show these families how the water filters work, and then each team is assigned to “walk home” with a family and get them set up. We walk for a long time through thick forest and vegetation to reach our family’s home. The house is made of dried mud bricks with kind of a grass and tin roof. There is a small “brick” cooking stove in the corner of one of the two rooms. All the cooking is done here using wood. The floor is dirt and there are no window coverings. This family is very glad to have the filter so that they can have clean drinking water. The three small children have all had health problems related to contaminated water. We return to the community center and go out with another family. It is a good day.
Day 8
Back to more schools. So many children. There are no “addresses” here…only GPS coordinates. If you wanted to send clothes or supplies it would be almost impossible. The best you could do would be to send it to San Pedro Sula 10 hours away, and wait for a staff person to have a reason to drive that distance. I can’t describe how remote it is. Women walk miles and miles with their small babies. One woman has walked three hours to see us with her son who has severe Cerebral Palsy. He is 12, but looks like 6. He is very tall, but very malnourished. She says she does not know if she can take care of him with all of her other children. She says she has “no hope” and wants us to help him die. In another life, on another planet, I might have felt this request was unreasonable---but here in this place…this place with so little. I have to bite my lip and fight back tears. The answer will be there is nothing we can do. There are no resources here, no visiting nurse, no respite care, no physical therapy, no nutritional assessment, there is nothing that can be done. I understand her when she says “no hope.” Forgive me, but I understand.
Day 9
It is a sad day in our compound. One of the interpreters assigned to our group has committed suicide. Suicide is actually quite common in this area...there are eight to 10 a year. This young woman was 17, she had two small children. Her husband had recently moved in with another woman and
started another family. This is not uncommon in Honduras. Many men have wives and girlfriends, and other families. This is a social issue that has gone on for some time. Theresa killed herself with rat poison…this is also a commonly used method, and not an easy way to die. We take a collection for her children and her family. The church bells ring for a long time.
Day 10
We begin the two day journey home. We pack up our bug huts and say good-bye to our cooks and the staff. We say good-bye to the vultures in the trees and the incredibly skinny dogs. I will miss the (almost) constant humming of the generator that has supplied us with electricity (most of the time). I know I will miss the sunrise and sunset over the mountains, and the beautiful, beautiful people. I read somewhere that it is a typically “Caucasian liberal” thing to say that people in developing countries are “very poor, but they are very happy.” It somehow makes us feel better. I think the people in rural Honduras manage with their life situation, they enjoy their families….but make no mistake, they struggle every day in ways you and I cannot even imagine. Every day is a challenge. Basic needs, in many cases, are not even met. What I do know is that the human spirit is strong. We get on our bus, quite changed from our arrival day. It is quiet, we are exhausted, we are humbled, we are thankful, we are nurses.
Day 11
I am now sitting on a plane heading back home; I find myself full of emotion. I twist the bracelet I bought from a woman on the roadside. Is this sustainable? Can Billings Clinic and MSU form some sort of partnership? Would other nurses want to have a similar experience? Does Billings Clinic want to have a global presence? All things to ponder.
Will I be back? ….more to come!
Respectfully submitted,
Terry Sauer, BSN, RNC Billings Clinic Nurse Manager, Pediatrics and Pediatric Specialty Medicine
Letter From the CEO
Nicholas Wolter, MDBillings Clinic CEO
Nursing Care: patient perspectiveNurses are near and dear to my heart, and this year I mean that literally as well. I recently experienced nursing care as a patient at Billings Clinic when I underwent open heart surgery to repair my aortic valve. I spent time recovering in both the ICU and ATU. I’ve always had great respect for nurses throughout my career, both as a physician and as an administrator, but my recent hospitalization brought home the value of nursing in a very personal way. The evidence-based quality and safety measures that our nursing staff follow and the caring and compassion shown to me and my family assured me that I was getting the best care possible. When a nurse in the ICU confiscated my Blackberry because I was supposed to be resting, I became acutely aware of who was in charge! Receiving Magnet designation and the Beacon Award for critical care excellence are huge accomplishments and the highest distinctions in nursing, but receiving excellent care as a patient here makes it all very real. Thank you for making a difference in my life.
34 35
www.billingsclinic.com
![[Annual Report] FY2010 Annual Report(FULL)](https://img.dokumen.tips/doc/110x75/58a19c0c1a28abf0428b88ed/annual-report-fy2010-annual-reportfull.jpg)
