Improving Retention through Implementation of a Nurse Externship

I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

Follow-up Text Messages for Patients at High Risk of Postpartum Hypertension Women’s Health

Purpose for the Program subset of postpartum patients in whom hypertension was diagnosed was readmitted within 7 days of giving birth at the hospital because of advancing disease. Our current practice for providing care to these women was to have them return for reevaluation at a 1-week follow-up appointment at our hypertensive clinic. As a result of our readmission data, we determined that increased outreach was needed between discharge Laura F. Scalise, RNC-MNN, time and follow-up time when subtle signs of adHospital of the University of Pennsylvania, Philadelphia, PA vancing disease may occur. Proposed Change Marilyn Stringer, PhD, To improve patient outcomes and decrease our WHCNP-BC, RDMS, 7-day readmission rate for this population, we piUniversity of Pennsylvania loted a nurse outreach program using text mesSchool of Nursing, sages (TM) as a tool to bridge this time gap. We Philadelphia, PA hypothesized that TM would provide the woman Keywords flexibility in response time that would better meet text messaging her and her infant’s needs during this early recovperinatal follow-up ery period. The implementation of TM is not time postpartum hypertension dependent, and the script can be cut and pasted quality improvement from patient to patient.

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Implementation, Outcomes, and Evaluation The purpose of this TM was to provide reassurance, answers to questions and problem-solving

solutions, and to identify women who needed escalated care. We developed a standardized TM that was sent to women 3 to 4 days after discharge. During our 3-month pilot (N = 123 patients), we observed a 34% (n = 41) response rate; 27% (n = 11) required a follow-up phone contact to attain additional information to determine if escalation was needed. In nine instances, phone triage was adequate in addressing concerns. Two of the 11 phone contacts indicated a need for escalation in care and referral to an acute care center. In one TM the woman stated, “I’m at the baby’s appointment and they checked my blood pressure and I think I need to go to the hospital but I have no way to get there.” In response to this woman’s needs, the nurse called the woman to obtain further assessment, determined that additional care was required, and facilitated the woman’s transport to care. Implications for Nursing Practice Nurses and participants expressed satisfaction with TM. Because of the success of this pilot program, we plan to offer it to all postpartum women in whom hypertension is diagnosed to determine whether our 7-day readmission rate for this issue decreases.

A Collaborative Maternal Arrest Safety Initiative Mary Ann Liner, CNP, APN, OSF Saint Francis Medical Center at Peoria, Peoria, IL

Purpose for the Program he American Heart Association’s (AHA) 2010 guidelines address cardiac arrest in pregMary Wheeler, RNC, BS, OSF nancy by providing a published algorithm and Saint Francis Medical Center, pregnancy specific modifications for managePeoria, IL ment. A health care provider’s ability to react prudently in an unexpected situation is one of the most Mildred Elaine Shafer, APN, critical factors in creating a positive outcome in MSHA, MS-PSL, OSF Saint Francis Medical Center, Peoria, an obstetric emergency. Researchers have shown IL that advanced cardiac life support (ACLS) certification may not necessarily translate to adequate Joshua Croland, MD, OSF performance of maternal resuscitation skills durSaint Francis Medical Center, ing an actual arrest. This maternal arrest pilot proPeoria, IL gram prepares participants how to manage this Keywords rare unpredictable obstetric emergency through maternal arrest in pregnancy simulated training experiences that pose no risk simulation to the mother or fetus.

(NICU) and Level-I trauma center located in central Illinois. The management of a maternal cardiac arrest requires the collaboration of several teams (obstetric, neonatal, anesthesia, nursing, hospital code, emergency medicine, and prehospital emergency medical services [EMS]) who rarely collaborate to come together to deliver consistent, excellent patient care. The ACLS classes at OSF do not include a comprehensive review of maternal resuscitation. This obstetric-focused pilot program will bridge this knowledge gap to include a didactic module and simulation component specific to resuscitation of the pregnant woman in conjunction with the current ACLS training program. This program for maternal arrest can span the entire OSF HealthCare system north central region to improve performance during a maternal arrest.

Proposed Change OSF Saint Francis Medical Center is a perinatal referral center with a neonatal intensive care unit

Implementation, Outcomes, and Evaluation An interdisciplinary team was involved in the pilot development and will serve as trainers. A

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2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

survey to assess current ACLS knowledge on maternal arrest will be administered before participants complete the didactic maternal arrest eLearning module. Data will be collected for comparison prelearning and postlearning. The participants include obstetric and emergency residents, registered nurses, anesthesia providers, and neonatal nurse practitioners. Using an obstetric mannequin, the in situ simulation component will be used to analyze the primary and secondary responder’s performance using real-life

maternal arrest scenarios, detect areas of deficiency in using the AHA-recommended algorithm, and discuss performance improvements. Presimulation and postsimulation confidence surveys will be completed. Implications for Nursing Practice Training, communicating, and solving problems in teams can affect maternal and fetal survival during a cardiac arrest. This collaboration will increase job satisfaction for all responders.

Simulation Training to Improve Competency and Confidence at the University of California San Diego, Women and Infants Services Brooke A. Sturgeon, MSN-ED, Purpose for the Program UCSD Medical Center, San o improve nursing and health care provider Diego, CA Keywords simulation staff nurses training events random drills

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staff competence and confidence in response to emergency events using simulation training events (STE). The initial data collected between 2011 and 2012 indicated that 70% of staff felt confident in participating in STEs; 62% demonstrated poor communication and slow response time in obstetric emergencies. No STEs were performed or offered, and no resident/intern/fellow and nursing staff participated in STEs.

Proposed Change To increase physician/provider and nursing staff comprehension of simulation education and training along with demonstration of competency to improve patient safety in obstetrics (OB). Participant comprehension of simulation education and training will be demonstrated by a pretest and posttest. Participant competency will be demonstrated by improved response time and communication. Implementation, Outcomes, and Evaluation This program was implemented by the labor and delivery (L&D) nurse educator and the director of OB residency simulation. Physician training classes will include education and will be hands on. Nursing staff simulation training will occur through the Obstetrical Drill Committee and Competency/Education Committee during a skills

training fair and special simulation training events. Effectiveness of the simulation program will be measured by comparing a presimulation and postsimulation training self-assessment evaluation that will be presented to all participants. At the conclusion of the program, four anticipated process outcomes were met: 96% (12% increase) of the staff felt confident in participating in simulation education and training; at least an annual 5% increase was demonstrated regarding improved communication and response time in obstetric emergencies; 20 STE drills were conducted over the course of the year; and 90% of faculty and staff participated in a simulation training session within a year of evaluation. Implications for Nursing Practice Perinatal patient safety initiatives are of national interest. Collaboration among multidisciplinary providers and nursing staff is necessary, and improving communication and practicing emergency responses has been shown to improve outcomes. STEs have been shown to be a successful method to improve the response time, competence, confidence, and communication of teams. Because nursing staff spends the most time at the bedside and plays a major role identifying mother/infant decompensation, it is essential to maintain competence in emergency response.

Implementing a Massive Transfusion Protocol in Labor and Delivery LaToya Scales, BSN, RNC-OB, Purpose for the Program Baylor University Medical urses in the labor and delivery unit at BayCenter, Dallas, TX

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lor University Medical Center recognized a

need to guide staff during a massive hemorrhage. Postpartum hemorrhages continue to be a leading cause of maternal death in the United States.

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Keywords hemorrhage massive transfusion protocol blood

Women’s Health Poster Presentation

Staff felt that developing an interdisciplinary protocol and standardized education would help foster timely communication that leads to improved patient outcomes. Proposed Change To develop an obstetric (OB)-specific massive transfusion protocol (MTP) by utilizing current evidence-based practice transfusion recommendations. Our hospital has had a MTP for many years. As a result of working in conjunction with the blood bank and the OB anesthesia unit, we also defined the nurse’s roles in caring for patients during massive hemorrhages and transfusions. This tool serves as a guide for nursing staff. By activating this MTP, we ensure that all appropriate parties are aware of the emergent situation. Implementation, Outcomes, and Evaluation We assessed the knowledge base of our staff before creating our education plan. The results from that the assessment suggested we focus on the definition of massive hemorrhage. Further-

more, the results indicated what labs to anticipate, which resources to utilize, and what the role of the nurse should be during a massive hemorrhage. Education focused on these key components in addition to the new obstetric MTP. To reiterate the components addressed through education and to focus on the nurses’ roles, all nursing staff were required to complete a simulation drill with the focus on massive hemorrhage and implementation of the protocol. The protocol was placed in all the delivery rooms, the operating room (OR), the recovery room, and the hemorrhage cart for quick reference. Implications for Nursing Practice Having a MTP in place for the labor and delivery staff allows for rapid and organized response in what can be a hectic emergency. Standardizing protocols and clearly defining responsibilities helped to outline steps for the interdisciplinary team to provide optimal treatment and effective communication.

Surgical Counts in the Delivery Room

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Tonnyann T. Hurley, MSN, RNC-OB, C-EFM, St. David’s North Austin Medical Center, Austin, TX Amy Meyer, RNC-OB, St. David’s Women’s Center of Texas, Austin, TX Keywords retained surgical items vaginal birth surgical counts

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Purpose for the Program n opportunity existed to reduce or eliminate the risk of retained surgical items (RSIs) in response to the Joint Commission’s October Sentinel Event Alert regarding RSIs. Within perinatal nursing there is a keen awareness that a discrepancy exists between the approaches to surgical counts in the perioperative suite versus the vaginal delivery room. It is very likely that during vaginal births, the surgical count error rate is greater than the overall 10% to 15% error rate noted by The Joint Commission.

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Proposed Change To implement a highly reliable and standardized count process during all vaginal births that was more in line with structured counts of the perioperative suites. Implementation, Outcomes, and Evaluation Although limited, the literature demonstrated the need to first revise the facility wide count policy and specifically address the count process for vaginal births. Next, informal staff surveys indicated that the existing process lacked clear expectations, identified significant gaps in the process, and confirmed breaks in communication between nursing and provider staff. These surveys also revealed that the team approached the

counts for vaginal births in a less formal manner than the surgical counts in the perioperative suite. Based on this information we implemented a standardized counting system that included a defined interdisciplinary communication requisite, streamlined the documentation, and provided global team education. Within 2 months of the completion of phase one training (hands on training) and the policy revision, the count sheet audits demonstrated greater than 95% adherence. After Phase 2 training, which included video demonstration and eLearning, greater than 98% adherence was demonstrated using 100% count sheet and random observed audits. In the 3rd and 4th month of observed audits, 100% adherence was noted, demonstrating normalization of the new process. Implications for Nursing Practice Primary outcomes included improved communication between health care providers and nurses, count diligence, and standardization of the count culture within the vaginal delivery room. In addition, the process change enhanced patient safety by minimizing the risk of the RSI in the vaginal delivery room. Finally, although not utilized in this process change, there is clearly a need to evaluate the effect of assistive safe count technology during vaginal births.

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

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Hurley, T. T.

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Adapting Nursing Care to Alternative Uses of the Placenta Gina M. Scott, MSN, RN, RNC-OB, Christiana Care Health System, Newark, DE Valerie Rappa Gray, BSN, RNC-OB, Christiana Care Health System, Wilmington, DE Kathy Brereton, BSN, RN, RNC-OB, Christiana Care Health System, New Castle, DE

Purpose for the Program n our large, Mid-Atlantic hospital, which has approximately 6500 births annually, an increasing number of women desire alternate methods to dispose of the placenta. These methods include burial and placentophagy (e.g., raw, cooked, or encapsulated). This presentation is an overview of how our unit is adapting to this emerging need.

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Proposed Change Pamela Kay Turner, RN, To assist staff nurses on the ethical, legal, and safe Christiana Health Care System, way to send the placenta home with the woman, Newark, DE a procedure is being developed. This practice will Keywords placenta rituals placentophagy

provide the staff nurse with education on the alleged benefits of placentophagy, the significance behind the ritual of placental burial, and hospital guidelines on how to package the placenta.

Implementation, Outcomes, and Evaluation We are creating a plan for this procedure. Our plan begins with revising the form for release of placenta. Next, we are designing an informative PowerPoint presentation to educate staff on alternate methods of placental disposal and the ethical sensitivity that should be expressed with this request. Staff also will receive an e-mailed tip of the month highlighting these guidelines. Finally, a convenient location will be designated for placenta kits, including container, material, and guidelines necessary to provide this service. Implications for Nursing Practice With education on rituals regarding the placenta, staff nurses will feel more confident and comfortable with handling the placenta, and this comfort level will be reflected in the guidance and sensitivity they offer their patients.

Childbearing Poster Presentation

Delayed Cord Clamping: A Multidisciplinary Approach Diana Rich, BSN, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Keywords delayed cord clamping policy development multidisciplinary team approach

Childbearing Poster Presentation

Purpose for the Program n evaluating adverse outcomes in our hospital, we recognized an opportunity to affect the rate of intraventricular hemorrhage (IVH) in infants born before 32 weeks gestation. Neonatal intensive care unit (NICU) nurses and neonatologists felt that preterm infants could benefit from delayed cord clamping (DCC) to reduce IVH rates by nearly 50%. Staff from labor and delivery (L&D) and the NICU partnered to develop and implement a process for DCC with the end goal of improving patient outcomes.

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Proposed Change To ensure success, an interdisciplinary team consisting of NICU and L&D nurses, neonatologists, obstetricians, and respiratory therapists was formed to develop a standardized process for cesarean and vaginal births. Implementation steps included establishing a policy for discussing essential steps needed to maintain normothermia of the infant, creating simulation videos for training on the process, and educating all physicians and staff within L&D and NICU.

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Implementation, Outcomes, and Evaluation A standardized approach to DCC was established by the multidisciplinary team. Using the Iowa model, benchmarking, and a current literature review, a policy was developed that included a clear set of exclusion criteria for all very-low-birth-weight (VLBW) infants. We set a specific time frame for the delay in clamping the cord and most importantly established clear communication guidelines for prompting the delivery team to next steps. The team worked together to discuss obstacles faced during vaginal and cesarean births in ensuring normothermia of these infants. The team walked through the proposed process in a simulated environment to ensure that all barriers had been considered and developed a simulation video to disseminate consistent training for the L&D and NICU staff. Because of the work of this multidisciplinary team, the hospital has experienced great success with implementing a consistent DCC process.

Implications for Nursing Practice Nurse involvement began at inception of this project and has continued through current implementation. The NICU staff actively communicated time frames to the delivery team, and labor

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I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

and delivery nurses regulated the delivery room temperature and ensured consistent communication throughout each preterm birth. Although delayed cord clamping did not increase staff work-

load, it was a process change for the nurses and physicians. The team provided input to perfect the process and balance safety with practicality and efficiency.

Role of the Obstetric Clinical Nurse Coordinator Purpose for the Program he scheduling of procedures on the unit was formally an ad hoc process. This resulted in no true clinical oversight of the procedures being scheduled. The American College of Obstetricians and Gynecologists, The Joint Commission, and Centers for Medicare & Medicaid Services call for regulation surrounding the elective induction of labor of pregnancies before 39 weeks gestation. There also are controlled criteria for exclusions to these guidelines. Gaps in adhering to the guidelines as well as patient and physician dissatisfaction resulted in the vision of a single point of contact for all women entering the obstetric unit for planned procedures.

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Proposed Change To have the obstetric clinical nurse coordinator play the role of the clinical nurse expert to shepherd women through the final stages of their pregnancies, help guide their transition from outpatient to inpatient setting, and ensure adherence to guidelines of scheduled procedures. Implementation, Outcomes, and Evaluation Before initiation of the role, the hospital had a high nulliparous elective induction rate. This translated to a failed induction rate of 25%. This number proved to be staggering and bolstered support

of a clinical expert to monitor scheduled procedures. Six-months postimplementation of the role, the rate of failed inductions decreased dramatically to 2% with enforcement of cervical Bishop scoring and adherence to the guidelines related to medical versus elective inductions. This remarkable change in the model of care also resulted in fewer elective inductions scheduled overall from 15% to 8%. The clinical nurse coordinator also is a driver of family-centered care. Women come to the unit already having established a relationship and point of contact in the inpatient units. This has resulted in high patient satisfaction scores with year-to-date overall inpatient satisfaction at 90.4% via Press Ganey. The number of delayed or cancelled inductions has decreased dramatically as well, and health care provider satisfaction has increased.

Nan Ybarra, MBA, BSN, RN, NEA-BC, Texas Children’s Hospital Pavilion for Women, Houston, TX Keywords clinical nurse coordinator patient centered evidence based practice expanded nursing roles

Childbearing Poster Presentation

Implications for Nursing Practice The role was not easily understood when first presented and resistance of the idea was met initially. The need for this change and desire to have a clinical nurse expert in the role, once occupied by a unit clerk, was met with skepticism. However, this model is now regarded as an exemplar of patient-focused, quality care. The quantitative and qualitative positive results affirm the vision of this role.

A TeamSTEPPS Approach to Improving the Pain Experience of Obstetric Patients Purpose for the Program o improve the pain experience of obstetric patients during the inpatient care continuum.

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Proposed Change To improve pain management as measured by our patients by utilizing a TeamSTEPPS-based approach through strategic use of technology to standardize pain management practices and medication regimens that account for transitions in care and common sources of pain.

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Implementation, Outcomes, and Evaluation A multidisciplinary team created computerized pain management order sets. These sets were used to standardize pain medications while taking into account the mode of birth (cesarean vs. vaginal), transitions in care (operating room to postanesthesia care unit and labor and delivery to postpartum), and medication pharmacokinetics to ensure proper timing of medication administration and reduce common medication errors. A multidisciplinary pain task force was created. This group designed and implemented a pain survey used to interview patients during

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Linda Gibbons, MS, RN, New York Presbyterian Hospital, New York, NY Keywords TeamSTEPPS pain management technology

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Gibbons, L.

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hospitalization. Feedback was used to identify future interventions. Real-time pain scores were made readily available to caregivers by displaying them on commonly used electronic screens. Additionally, pain rounds and focused event reviews were conducted. TeamSTEPPS concepts were applied. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey (PG) data comparing Q2 2013 (the quarter preceding TeamSTEPPS training) versus Q2 2014 (the most recent intervention) were reviewed. The positive trend across all pain measures for both surveys suggests our pain management program is having a positive effect.

Gaps identified in our program include failure to discuss patient expectations before admission, lack of available obstetric (OB)-specific pain management educational materials, lack of understanding of many patients regarding their pain management plans of care, and lack of guidelines for administration of intravenously controlled substances during labor. Specific future interventions were developed to address each of these gaps. Implications for Nursing Practice Nurses can have a significant effect on the pain experience of patients. It is essential for nurses to participate in team-based problem solving techniques to address the many layers of complex, multidisciplinary issues affecting this pain experience.

Implementing Complete Couplet Care Lori Davies, MSN, RNC-OB, Frederick Memorial Hospital, Frederick, MD Candice Michael, RNC-OB, Frederick Memorial Hospital, Frederick, MD

Purpose for the Program ecognizing that the best place for a stable newborn is with its mother, a collaborative effort was made to change practices and workflows to eliminate unnecessary separation of mothers and their newborns. This initiative was given the descriptive name of complete couplet care (CCC).

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Keywords couplet care Proposed Change skin-to-skin contact early initiation of breastfeeding To implement the CCC, that is, the mother/infant

Childbearing Poster Presentation

dyad would remain intact unless separation was indicated for medical or safety reasons. Nursing interventions, pediatrician examinations, and most testing and procedures would occur at the mother’s bedside. Implementation, Outcomes, and Evaluation To garner support for CCC, nursing staff attended a brainstorming session and were encouraged to contribute strengths, weaknesses, opportunities, and threats to the proposed practice change. Feedback was reviewed, and recurring themes were identified. Task forces were formed. One group reviewed current literature and implemented skin-to-skin contact (SSC) after all appropriate births. Another task force developed a plan for bath at bedside so that initial newborn baths were completed at 6- to 12-hours of life in the mother’s room as a teaching tool for parents. The position of newborn assessment nurse (NAN) was created to provide initial care in the delivery room. Task forces combined and began collaborative

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efforts to implement unit-wide changes that would facilitate CCC. It was soon recognized that CCC would have farreaching implications. Pediatrician buy-in was imperative as newborn examinations would move to the mother’s room. Ancillary departments such as registration, information technology, lab, housekeeping, dietary, and respiratory therapy would be affected by changes in the workflow. Representatives from these departments were involved in planning to assist them in making the transition to CCC. Site visits to other facilities were conducted to generate ideas for best practice. Initiation of CCC occurred on February 4, 2014. Since implementation, there has been a significant improvement in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, surpassing goals. The time from birth to initial breastfeeding has decreased, especially for cesareans. Based on feedback obtained from daily nurse manager rounding, the patient response to the implementation of CCC has been overwhelmingly positive. Implications for Nursing Practice Implementation of CCC required alterations in routines for maternal and newborn care. Collaborative planning and staged implementation assisted nursing staff, health care providers, and ancillary departments to embrace the concepts of CCC. Now care is brought to the bedside to prevent unnecessary separation of the mother–infant dyad.

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A Multidisciplinary Approach to Bringing the Obstetric Emergency Team Together Purpose for the Program urrent evidence indicates that maternal mortality rates are increasing. The purpose of this project was to initiate a program that would improve multidisciplinary communication, increase efficiency, decrease staff confusion, and improve patient outcomes during an obstetric emergency.

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Proposed Change To quickly bring the integral maternal-child personnel together in order to address the obstetric emergency, three separate unique codes (code Neo [neonatology], code OB [obstetric], and code L&D [labor and delivery]) were developed. The current practice was to individually call each physician, registered nurse (RN), technician, or ancillary staff member needed in the event of an obstetric emergency. This amounted to seven or more separate phone calls and could take several minutes; time was potentially taken away from intervening and treating a patient in an emergent situation. Implementation, Outcomes, and Evaluation Implementation involved collaboration and coordination with several departments along with educating staff and physicians about the benefits of having OB specific code teams. A policy was written to specifically describe each code: Code Neo, an emergency involving the resuscitation of a neonate; Code OB, a emergent postpartum hemorrhage or ecliptic seizure; Code L&D, a crash ce-

sarean. The new policy outlined the different roles of each team member and identified who was required to respond to each code. The Code Neo, Code OB, and Code L&D concept was presented at physician department meetings. A Mock Code Committee was developed involving RNs, physicians, and several ancillary departments. Maternal/child staff was educated, mock codes were performed, and a date was set for implementation. Pagers were distributed to everyone on the code teams. During implementation, meetings were continued to discuss and resolve issues and to promote full adoption. A survey was conducted to assess the maternal/child staff’s ability to handle an emergency situation preimplementation and postimplementation. Between October 2013 (implementation) and August 15, 2014, a total of 27 mock codes had been completed and staff had responded to 39 obstetric emergencies. As a result of the program’s implementation, response time during an obstetric emergency decreased significantly and team members have become more comfortable in their roles. Positive feedback also was obtained from the postimplementation staff survey.

Leah Romine, BSN, RNC-OB, PHN, Torrance Memorial Medical Center, Torrance, CA Keywords obstetric emergency communication collaboration

Childbearing Poster Presentation

Implications for Nursing Practice Only one phone call is now needed to activate the OB emergency team. Implementation of this program has resulted in increased multidisciplinary communication, increased staff confidence, and improved patient outcomes.

Decreasing Assessment to Disposition Time in Labor and Delivery Triage Purpose for the Program he purpose of this program was to enhance efficiency in a labor and delivery (L&D) triage managed by registered nurses (RNs).

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Proposed Change The Anne Arundel Medical Center (AAMC) L&D staff implemented five major changes in triage. These changes started with decreasing registration time to facilitate timeliness in getting the woman to triage. The creation of a patient care technician (PCT) position expedited entry of the woman’s information into the Electronic Medical Record. Defining standard work for nurses and creating a standard physician triage order set completed the process and made it more efficient.

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Implementation, Outcomes, and Evaluation AAMC’s L&D nursing team examined the triage process in 2012 when the average time in triage was 166 minutes. In 2013, after staff education and the incorporation of changes into nursing and PCT practices, the average time in triage decreased by 20%.

Robin Colchagoff, MSN, RNC-OB, CCE, Anne Arundel Medical Center, Stevensville, MD

Implications for Nursing Practice Exploring triage patient flow and a willingness to make changes resulted in a decrease in time from assessment to disposition in triage. Decreasing total length of stay in triage improves staff efficiency and patient satisfaction.

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JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Keywords triage efficiency patient satisfaction

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Romine, L.

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Screening for Perinatal Depression at County WIC Offices Barbara J. Fritz, BN, Alameda Purpose for the Program County Public Health, Oakland, o train staff of the Special Supplemental NuCA Keywords postpartum depression cultural competence screening for depression community services

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trition Program for Women, Infants, Children (WIC) in the administration of a perinatal depression screening tool appropriate in a culturally and linguistically diverse population. Behavioral Health Care Services helped to designated specific health care providers to be contacted in cases (based on screening tool scores) that required immediate or urgent response.

Proposed Change Postpartum depression (PPD) affects 10% to 12% of women worldwide, and its effect on families can be devastating. PPD has been associated with discontinuation of breastfeeding, child abuse and neglect, developmental delays, and exacerbation of mental health illnesses. Perinatal public health nurses (PHNs) have years of expertise in the use of screening tools and the care of women with PPD. WIC clinics are a convenient venue to expand screening and referrals for PPD. Implementation, Outcomes, and Evaluation The county WIC administrator, Behavioral Health Care Services, and local graduate nursing stu-

dents provided support for the program. A 2-day curriculum for WIC staff was developed by the lead PHN that included use of the Edinburgh Postnatal Depression Scale (EPDS), case scenarios, and practice screening. As of May 2014, more than 6000 women were screened at two WIC sites. Approximately 14% had positive test results, and 37% accepted referrals. Because of the protected nature of behavioral health care data, it is difficult to obtain a measure of client well-being. The program is expanding to additional WIC sites in the county.

Implications for Nursing Practice Screening for PPD and consequences of untreated PPD can be devastating for a family and community. Screening in community settings can lessen the stigma. As staff became confident in their administration and referral skills related to screening, their comfort level increased. Nurses developed this program, which speaks to the value of the nursing profession. This program may inspire similar ventures in other communities.

A Collaboration of Providers and Registered Nurses on Early Assessment and Identification of Patients with Risk Factors for Postpartum Hemorrhage Purpose for the Program o prevent harm to the woman, health care providers and nursing staff collaborated to implement early identification triggers for women at risk of postpartum hemorrhage (PPH). Audit inforBarbara Gesme, RN-CNEP, BSN, MSN/MBA, Bon Secours mation was collected from six women who experienced PPH in May 2014. The obstetric units conSt. Francis Medical Center, sist of 16 beds in the labor and delivery unit and Midlothian, VA 15 beds in the mother/infant unit in a communityKeywords based medical center. During the audits, the postpartum hemorrhage chief of obstetrics and the administrative director hemorrhage trigger tool questioned if the hemorrhages could have been provider–nurse collaboration prevented. Erin T. Robson, MSN/Ed, RNC-NIC, Bon Secours St. Francis Medical Center, Midlothian, VA

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Proposed Change Nursing staff receive education on PPH, and a hemorrhage cart is accessible on the individual units. Provider involvement became essential as concern was voiced over lack of patient information during physician hand-off. Literature re-

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view took place and evidence was presented during a perinatal collaborative meeting consisting of physicians, nurses, quality representatives, and the risk manager. The Maternal Safety Bundle for Obstetric Hemorrhage published by the American College of Obstetricians and Gynecologists guided creation the program. Quarterly, nursing staff are taught to recognize PPH. Early recognition and prevention of PPH were ranked as top priorities that fueled the implementation of the project. Implementation, Outcomes, and Evaluation Education was performed with health care providers and nurses on a trigger tool constructed for women at risk of PPH. During initial assessment of the woman in triage or labor, the nurse is able to identify medium or high risk of PPH by using a laminated risk assessment tool found at each bedside. The trigger tool includes risk factors from the

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antepartum period, admission to labor and delivery, and the intrapartum period. At any time during changes in levels of care, the woman can be identified as being at medium or high risk for PPH, and a two-dimensional magnet will placed on the doorframe outside her room. Continuous evaluation is performed to ensure trigger tool and visual cues are used.

Implications for Nursing Practice The magnet is a visual cue for nursing staff and other health care providers to indicate that a woman is at risk of PPH. The visual cue is useful when entering the room of a woman who is giving birth or when performing postpartum assessment of a woman with whom the provider is not familiar. The provider is now alerted to an increased risk of hemorrhage. Nursing staff appreciate the visual cue when a call bell is activated.

Labor and Birth Improvements at Mercy Hospital St. Louis Purpose for the Program ercy Hospital St. Louis is ranked among the top 20 hospitals in the nation related to birth volume, and approximately 8600 neonates are born there annually. In 2009, it became obvious the labor and birth unit in this hospital needed significant updating so the decision was made to build a new unit. In the months post move, the team recognized that many of the workflow processes and culture needed to change based on new demands.

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Proposed Change To begin the process, the organization turned to Lean daily huddles called “innovation time.” This protected time with no meetings allowed all unit leaders, managers, and senior staff time to take Gemba walks, observe unit operations, seek improvements, and remove barriers in the moment. This approach has dramatically improved team understanding of accountable metrics and has led to ideas to improve those metrics and communication across the organization. With new coworker engagement, the unit embarked on a 9-month Lean project to evaluate current processes and clarify future goals. Each month a group of frontline coworkers and supervisors came together for a week-long rapid improvement event (RIE) to work through A3

process improvement methodology, observe the Heather Thompson, MSN, RN, current state, trial new solutions, study results, and CENP, Mercy Hospital St. Louis, St. Louis, MO create a plan for implementation. Implementation, Outcomes, and Evaluation Major improvements were seen in scheduled induction times and operating room (OR) cesarean birth and recovery times. Only 47% of women were being seen on time for scheduled inductions, which decreased patient and physician satisfaction and influenced women to seek health care at competing hospitals. By creating standard work in the process, the patient satisfaction rate increased to 85% within the first month and was 98% by March. The rate of on time cesareans increased from 52% to 74% through reassigning staff roles and implementing standard work. With a 2-hour recovery time for these cases, only 29% of women met that goal, and most fell into a 2½- to 3-hour recovery period. After the RIE, 50% of women met the goal.

Tony Vago, MBA, MPA, CSSBB, Mercy Hospital St. Louis, St. Louis, MO Ashley M. Bell, MSN, RN, Mercy Hospital St. Louis, St. Louis, MO Keywords Lean methodology Mercy Hospital health care labor and birth nursing

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Implications for Nursing Practice The labor and birth unit at Mercy Hospital St. Louis is experiencing a 6.8% growth, whereas the overall local market is down 3.8%. The desire to continue to provide exceptional care while being reminded of the current dynamic health care environment motivates us to continuously improve and maximize value for our patients.

Implementation of an Obstetric Emergency Response Bag Purpose for the Program he development and implementation of an emergency response kit to provide standardized care to women with postpartum hemorrhage (PPH) in the postpartum unit.

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Proposed Change To create a Grab & Go bag containing essential first-line emergency response supplies

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in a standardized location on three postpartum Cathy M. Gilson, MHA, BSN, RNC-OB, South Shore units. Hospital, South Weymouth, MA

Implementation, Outcomes, and Evaluation Implementation included the following: debriefing Beverly Ferreira, ADN, South after an event and identification of multiple inter- Shore Hospital, South ruptions in care because of repeated trips to mul- Weymouth, MA tiple locations for supplies. Using the shared governance model and Lean process improvement

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Gilson, C. M., Ferreira, B., and Tose, M. A.

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Marjorie A. Tose, RN, BSN, South Shore Hospital, So Weymouth, MA Keywords PPH OB emergency bag mock drills

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methodology, the responders collaborated to create the initial supply list. The purchase and trial of several bags for size, accessibility, and ease of use along with handson education allowed staff to gain familiarity with the contents of the bags. The program included a defined standardized location within medication rooms on all three postpartum units, a system for maintenance and checking supplies in the bag, and a cheat sheet for quick access to PPH medications from the Pyxis station. Initial videotaped mock drills demonstrated the number of interruptions and delays in care before implementation of the Grab & Go bags. After several plan-do-study-act (PDSA) processes, mock

drills demonstrated a faster response time as a result of the Grab & Go bags. The need to repeatedly leave the room to retrieve additional supplies was significantly reduced. Implications for Nursing Practice Staff registered nurses (RNs) took a leadership role to improve practice and standardize response in emergency situations. Successful development and implementation of the Grab & Go obstetric emergency bag has increased RN confidence and improved quality of care during PPH and in response to other obstetric emergencies. During the process we highlighted the need to establish maternal rapid response teams that are currently under development.

The Fast Track from a New Practice Recommendation to Nurse Sensitive Indicator Alyssa Elaine Leimberger, Purpose for the Program RNC-OB, BSN, Bon Secours n response to the recent surge in pertussis St. Mary’s Hospital, Richmond, across the United States, specific recommenVA

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Jennifer Brickey, RN, Bon Secours St. Mary’s Hospital, Richmond, VA Kasondra Lynn Miller, RNC-OB, C-EFM, Bon Secours St. Mary’s Hospital, Richmond, VA Keywords Tdap vaccination

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dations for pregnant women have been made by the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) along with the American College of Obstetricians and Gynecologists (ACOG). Infants younger than age 6 months, who are too young to be vaccinated against pertussis, are the most vulnerable population with the highest mortality from this disease. The recommendations from ACIP and ACOG focus on protecting the newborn directly by targeting vaccination of the pregnant mother (to maximize maternal antibody response and passive immunity transfer to the newborn) and indirectly by cocooning (ensuring up-to-date vaccination status of family members and care givers who will be around the newborn).

Proposed Change To expedite implementing the evolving recommendations at the bedside in our labor and delivery, antepartum, and mother/infant units by utilizing different areas of focus, including maximizing the Electronic Medical Record (EMR) for patient screening and reporting, initial and ongoing staff education, increased surveillance, implementation of a nurse driven protocol, streamlining availability of the vaccine, and implementing a family and caregiver vaccination program.

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Implementation, Outcomes, and Evaluation We created a patient screening tool within the admission database in the EMR, developed new reports to accurately assess vaccination status of perinatal patients, provided initial and ongoing staff education and vaccination, increased routine surveillance for adherence, implemented a nurse driven protocol to facilitate administration, streamlined availability of the vaccine on the units, and implemented a family and caregiver vaccination program. During the initial 7-month period, approximately one half of the eligible patients were vaccinated before admission. We educated, screened for eligibility, and administered the vaccine for the other half. During this period, our tetanus–diphtheria– pertussis (Tdap) vaccination rate increased from 46% to 84%. Initially, we were steadily missing vaccinating between 33% and 54% of the eligible women who came into our facility who said they wanted the vaccine. After identifying nurse barriers to vaccination and implementing a nursedriven vaccine protocol we were able to decrease the missed rate to 16% within the first month. Additionally, we partnered with our outpatient pharmacy to pilot a family and caregiver vaccination program. Implications for Nursing Practice Tdap vaccination is nursing sensitive. Screening all perinatal patients for eligibility and implementing a nurse driven protocol positively affects vaccination rates.

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Implementing an Enhanced Birth Experience for Family-Centered Cesarean Birth Purpose for the Program o create a more family-centered birth experience for the woman undergoing a cesarean birth.

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Proposed Change Based on evidence, our perinatal clinical practice committee chose to implement specific changes to create an enhanced birth experience called Family-Centered C-Section. We realized that about one third of our patients did not get to experience a home-like birthing environment or have immediate skin-to-skin contact with their newborns. Our interventions included dim operating room (OR) lighting, patient-selected music, minimal to no family separation (i.e., support person remains at the patient’s side through the entire perioperative period), skin-to-skin contact, and initiating breastfeeding in the OR. Implementation, Outcomes, and Evaluation A multidisciplinary team approach was taken: labor and delivery (L&D) nurses, anesthesiologists, obstetricians, pediatric hospitalists, nursery nurses, neonatal nurse practitioners, OR technicians and nurses, and maintenance personnel all had input into the innovative practice. Logistical issues were considered and resolved. Equipment was moved around the room in different positions, electrical work was done to dim the overhead fluorescent lights, and speakers were purchased with dock and auxiliary jacks for phones

to play music. Education for the nurses and physicians followed regarding the new process. Like any change, we encountered staff who were excited and staff who did not allow for some of the interventions to take place. Further education and role-modeling helped with staff that were reluctant.

Amy Lavigne, BSN, RNC-OB, C-EFM, Vail Valley Medical Center, Vail, CO Sarah R. Washburn, MS, RNC-OB, IBCLC, Vail Valley Medical Center, Vail, CO

Patients have expressed satisfaction in the new process, especially if they had previous ce- Colleen Gosiewski, BSN, RN, sarean births without the interventions. Families Vail Valley Medical Center, Vail, CO are amazed that their newborns are able to breastfeed while the mother is still on the operating table. Implications for Nursing Practice Shared governance is an important aspect for implementing changes in the unit. The process reflected the desire of the practice council members. All of the interventions were evidence based. For example, music and minimal separation of the support person allows for decreased anxiety and heart rate. Our previous staffing guidelines in which a nurse was responsible for the newborn allowed us to easily transition to keeping the newborn with the mother for the entire procedure (skin-to-skin contact and providing breastfeeding support). Another nursing implication is that our patients are educated in the office, visit our hospital website, and participate in prenatal classes about our Family-Centered C-Sections, so the expectation has been set in the community. Nurses and physicians who do not follow the interventions often are questioned or reminded by patients, families, and other staff members.

Andrea Kuester, BSN, RN, Vail Valley Medical Center, Vail, CO Keywords family-centered care cesarean birth skin-to-skin breastfeeding

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Using the Lean Process to Achieve Skin-to-Skin after Cesarean Births Purpose for the Program o use Lean improvement methods to improve a clinical process: facilitating skin-to-skin contact between the mother and newborn after cesarean birth.

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Proposed Change The goal of this project was to establish a process to facilitate keeping the mother and newborn together and provide skin-to-skin contact in the operating room or recovery room after cesarean birth. Previously, we separated the mother and newborn and moved the newborn to the nursery for assessment while the mother remained

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in the birth center, which delayed skin-to-skin Kim Price, MBA, MSN, RN, Centra, Lynchburg, VA contact. Implementation, Outcomes, and Evaluation Lean improvement project team members included process engineers, nurses, managers and director. Lean methods used included spaghetti mapping, Gemba walks, and identification of process waste. Following a plan, do, check, act (PDCA) trial, the team identified the following issues: resistance from anesthesiologists,; confusion regarding communication paths, and a need for educational tools to clarify the process and contraindications. Anesthesiologists were provided with published evidence and the

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Jackie Weaver, BSN, RN, Centra, Lynchburg, VA Stacey B. Tribbett, MSN, RNC-OB, Centra, Lynchburg, VA Christine Carpenter, BS, Centra, Lynchburg, VA

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Price, K., Weaver, J., Tribbett, S. B., and Carpenter, C.

I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

Keywords Lean improvement skin-to-skin cesarean baby friendly

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opportunity to discuss their concerns with physician colleagues at another hospital who were already providing skin-to-skin contact in the operating room. Posters outlining the communication paths and process changes for each area were provided. The team determined criteria for contraindicating participation in skin-to-skin contact and designed process maps for complicated versus uncomplicated births. Project outcomes include changes in work function, which enables the newborn nurse to be the newborn response nurse, enhanced communication between the clinical areas, and the establishment of a transitional nursery within the neonatal nursery. Participation empowered staff to initiate changes related to nurse station redesign for improved work flow and development of a Baby Passport to assist with discharge preparation. During the 1-month PDCA trial, skin-to-skin after cesarean increased from 0% to 15% over-

all. Continued focus will be on monitoring exclusive breastfeeding rates, initiation and duration of skin-to-skin contact, staff education, and quality review. Implications for Nursing Practice The 10 Steps to Successful Breastfeeding from the Baby Friendly Hospital Initiative through the World Health Organization (WHO) and UNICEF include the initiation of breastfeeding within 1 hour of birth. By minimizing separation of mothers and newborns after a cesarean, breastfeeding can occur sooner. Skin-to-skin contact between the mother and newborn provides improved infant temperature, more stable glucose regulation, and increased maternal bonding. The use of Lean methods for improvement to provide skin-to-skin contact resulted in improved processes and empowered nurses to identify additional improvement opportunities.

Patient Falls in Labor and Delivery Brenda Baker, PhD, RNC, CNS, Virginia Commonwealth University Health System, Richmond, VA Jeanette Dupree, RN, BSN, Virginia Commonwealth University Health System, Richmond, VA Keywords falls pregnancy perinatal

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Purpose for the Program t an urban academic medical center with approximately 2200 births per year, 10 falls occurred in labor and delivery (L&D) unit in a 12-month period. None of the patients who fell was categorized, as high risk for falling, which led the nurses to ask if the current risk scale for falls was useful in the perinatal population. The hospitalwide falls screening tool had little application in the perinatal population because the tool was validated in the geriatric population. A review of the literature revealed little evidence as most studies excluded perinatal patients from their validation work. The purpose of this project was to create an obstetric specific falls prevention program and screening tool to identify women at risk of falling and decrease the number of falls in the L&D unit.

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Proposed Change To create a population specific falls prevention program and screening tool to identify pregnant women at risk of falling and decrease the incidence of falls in the perinatal population. Implementation, Outcomes, and Evaluation A review of literature was conducted using CINAHL and PubMed. Search terms included falls

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and pregnancy. Nine publications related to falls in pregnancy met search the criteria. Findings from this review indicated history of previous fall, visual disturbances, sedentary life style, and edema in feet and ankles during pregnancy as most predictive of risk of falling. Along with the review of literature, an in-depth analysis of each fall event was completed. This work lead to development of a clinical practice guideline, Falls Prevention in Labor & Delivery, and a population-specific screening tool built in the Electronic Medical Record. Staff education and monthly chart audits were conducted to monitor adherence to the tool and to provide feedback related to use of the screening tool. In 2008, 10 falls were reported. After the implementation of the obstetric falls program, two falls were reported in 2013.

Implications for Nursing Practice A continual decline in patient falls in L&D has occurred since implementation of multiple initiatives, including a population specific screening tool. Future plans include validation of the screening tool.

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How Our Hospital Successfully Reduced Cesarean Rates Purpose for the Program o demonstrate how one Washington state hospital reduced its cesarean delivery rate dramatically by implementing a Centers for Medicare & Medicaid Services (CMS)-funded project called Leading Edge Advanced Practice Topics (LEAPT) as part of a larger project to help reduce cesarean births regionally and nationally.

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Proposed Change To decrease the rate of cesarean births, the project, which occurred from December 2013 to December 2014, involved labor and induction management tools/bundles and patient education.

Implementation, Outcomes, and Evaluation The tools were piloted, revised, and implemented with great success. Sustained improvement occurred, and cesarean and induction rates dramatically decreased over the course of the project. An unexpected outcome was improvement in collaborative practice, registered nurse (RN) to provider communication, and better patient education around term gestation and nonmedical inductions.

Trish L. Nilsen, BSN, RNC-OB, Whidbey General Hospital/Whidbey Family Birthplace, Coupeville, WA

Implications for Nursing Practice RNs play a pivotal role in changing practice in a clinical care setting involving other providers who share management of the patient. Success celebrated by the care team can stimulate further growth and practices can then become the new norm.

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Keywords cesarean delivery reduction nonmedical induction of labor patient education interdisciplinary management of labor

Integration of a Mental Health Professional in a Multidisciplinary Team Caring for the Pregnant Woman after Diagnosis of Fetal Anomaly Purpose for the Program regnancy is a time of psychologic change for women and their families. Even women with uncomplicated pregnancies report increased rates of depression, stress, and anxiety during the perinatal period. In addition, maternal mental health conditions may complicate 13% to 25% of all healthy pregnancies. The prenatal diagnosis of a fetal structural or genetic abnormality may further compound the psychologic effect on the pregnant woman. The Center for Fetal Diagnosis and Treatment and the Garbose Family Special Delivery Unit are outpatient and inpatient programs dedicated to caring for women experiencing pregnancies complicated by fetal anomalies. With increasing evidence that prenatal stress, anxiety, and preexisting mental health conditions may have long-term sequelae for the pregnant woman, her fetus, and the family, it was imperative that these concerns be addressed.

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Proposed Change To add a mental health professional to our multidisciplinary team. Philanthropic funding was generated and a clinical psychologist with perinatal experience was hired in 2012. This embedded provider partners with nursing staff and is in the unique position to offer assessment and immediate intervention to support women and families

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during the prenatal course, into intrapartum care, and throughout the postpartum period while their newborns are in the neonatal intensive care unit (NICU). Implementation, Outcomes, and Evaluation To better understand the base rate of maternal mental health risks, the psychologist initiated a standardized screening tool to identify those expectant mothers and fathers at greatest risk of psychologic distress in response to the diagnosis of fetal abnormality. The goal of screening is to provide prenatal intervention at the earliest possible point in care to reduce symptoms in the postpartum period. Patients demonstrating risks of depression, anxiety, or traumatic stress are connected to therapeutic services offered in the same location as prenatal care. Nursing staff continue to evaluate patient well-being during routine prenatal care and can make direct referrals to the psychologist as needed. Implications for Nursing Practice Nurses are ideally situated to provide familycentered obstetric care for these women and their families. A woman’s preexisting mental health diagnosis or an acute psychologic challenge related to the fetal anomaly may entail a higher level of psychosocial intervention than nurses are trained

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Susan R. Miesnik, MSN, RNC-OB, CRNP, The Children’s Hospital of Philadelphia, Philadelphia, PA Joanna CM Cole, PhD, CD (DONA), The Children’s Hospital of Philadelphia, Philadelphia, PA Tyra Jones, RNC-OB, MSN, CRNP, The Children’s Hospital of Philadelphia, Philadelphia, PA Keywords perinatal mood disorders fetal anomalies perinatal psychology maternal mental health psychosocial nursing

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Miesnik, S. R., Cole, J. C. M., and Jones, T.

I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

to provide. Close collaboration between the nurse and the mental health professional ensures that

obstetric management will be coordinated with psychologic care to optimize outcomes for the woman and her family.

Reducing Infection Rates after Cesarean Birth Cindra S. Holland, DNP, Purpose for the Program RNC-OB, ACNS-BC, Kettering he purpose of this innovative educational proMedical Center, Kettering, OH gram was to implement changes to reduce the and Wright State University, rate of infection after cesarean at a Midwestern reDayton, OH

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gional health care facility. From 2011 to 2013, this rate ranged from 0.62% to 1.23%. Clearly, there is Katie Adkins, BSN, RNC-MNN, Kettering Medical an upward trend in the rate of infection that needs to be managed to decrease postoperative infecCenter, Kettering, OH tions. Peggy Foster, MSN, RNC-OB, C-EFM, Kettering Medical Center, Kettering, OH Deborah Ulrich, PhD, RN, Wright State University, Dayton, OH Kim Job, BSN, cEFM, Kettering Medical Center, Kettering, OH Jessica Akemon, MS, RN, Kettering Medical Center, Kettering, OH

Proposed Change To implement standardized preoperative and postoperative education for all women who have cesarean births. Implementation, Outcomes, and Evaluation The interdisciplinary, evidence-based practice (EBP) project involved physicians, nurses, and staff in obstetric offices and nurses and educators in the labor and delivery and postpartum units. A retrospective chart review was conducted of women who experienced infections after cesarean for 99 variables. No common variables were iden-

tified regarding etiology of postcesarean delivery infections. A review of the literature was conducted, and patient education was identified as an intervention that affected infection rates. The interdisciplinary team created standardized preoperative instructions and standardized postoperative instructions that include an educational pamphlet and DVD. The projected program outcome is a decrease in the rate of infection after cesarean at the facility. Project outcomes will be measured by tracking infection rates quarterly and yearly. Preimplementation and postimplementation outcome data will be compared. Implications for Nursing Practice It is important that nurses are educated on how to identify best practices to provide consistent education to women from the time they decide on cesarean birth to discharge. It is imperative that nurses know how to implement best practices to improve patient outcomes. Reduced rates of infection will also reduce cost and morbidity associate with cesareans.

Keywords cesarean postoperative infection patient education

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Notification of Obstetric Emergency Nan Ybarra, MBA, BSN, RN, NEA-BC, Texas Children’s Hospital Pavilion for Women, Houston, TX Keywords OB emergency notification patient safety

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Purpose for the Program mergency activation models relied on the nurse pressing the nurse call button and requesting help, vocally calling out for help, and then relying on a person to notify each team member needed in the response effort. This meant that other staff had to be able to hear and respond to a nurse’s calls, and nonclinical personnel had to be available to relay medical information to physicians and other care team members. The response was unfocused and highly variable.

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Proposed Change To implement swift notification of team response in obstetric (OB) emergencies using a cap code

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pager team and smart panel technology already available in every patient room and operating rooms. Response buttons were built for massive transfusion protocol (MTP) team response, emergency cesarean delivery (ECD) team response, and stat anesthesia team response. The team members on the response teams will vary slightly, but the recurring members on the MTP and ECD team include emergency response nursing staff from the labor and delivery unit. These nurses will carry pagers and phones that will alert them to the location of the patient and type of code response. Notification to all the various medical team members will mirror the same process, pager, and phone notification. The most vital change involves

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a free OB emergency response nurse to support the bedside nurse and elevate the level of care needed.

creased time from decision to incision. Opportunities to improve closed-loop communication and role refinement exist.

Implementation, Outcomes, and Evaluation Smart panel technology in all existing rooms with emergency notification buttons added to trigger mass page to all identified OB emergency team members. Development and testing of workflows with multiple simulations prior to roll out. There was decreased time spent notifying individual team members, decreased time moving from the labor and delivery room to the operating room, and de-

Implications for Nursing Practice The use of the smart panel technology will allow for the nurse to press a single button and notify all the specific care team members needed without having to leave the patient’s room or cry out for help. The minutes once spent scrambling to find help will now be spent initiating lifesaving measuring for the patient and preparing for the next phase of care.

Achieving the Triple Aim of Accredited Birth Centers Purpose for the Program o describe accredited birth centers and their role in the U.S. maternity care system.

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Proposed Change To provide factual information to professional perinatal nurses to promote collaborative care across systems. Implementation, Outcomes, and Evaluation Compare outcomes of selected birth centers to average U.S. statistics using Healthy People 2020 maternal, child, and infant objectives. Compare costs of birth centers to traditional U.S. maternity care and present patient satisfaction rates of

selected birth centers. The results indicated that birth centers are achieving the elusive triple aim in maternity health care, and their numbers are growing rapidly across the United States. Implications for Nursing Practice Out-of-hospital birth rates are increasing in the United States, and up to two thirds of women say they would consider birth center care for future pregnancies. Nurses own, direct, and staff birth centers, and nurses receive and care for women who transfer from the out-of-hospital setting to tertiary care. Collaborative care is vital to the safety of all women, regardless of their chosen birth site.

Olga R. Ryan, MS-NL, RN, Commission for the Accreditation of Birth Centers, Tucson, AZ Keywords midwifery out-of-hospital birth accreditation triple aim birth center freestanding collaboration

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Initiation of Group Prenatal Care in the Center for Fetal Diagnosis and Treatment Purpose for the Program roup prenatal care has been piloted in the Center for Fetal Diagnosis and Treatment as an intervention designed to improve psychosocial outcomes in a high-risk population. The Center for Fetal Diagnosis and Treatment is a unique, referral-based program for women whose pregnancies are complicated by prenatally diagnosed fetal anomalies. These women receive prenatal care and give birth in the same facility where their neonates receive postnatal care. This intervention is based on the premise that group care is most effective and efficient when groups are facilitated rather than taught.

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Proposed Change Group prenatal care at the Center for Fetal Diagnosis and Treatment represents a care delivery system that is an alternative to the medical ill-

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ness model of pregnancy and encompasses care for the fetus and mother. Applying principles from the Centering Pregnancy model, sessions consist of health assessment, education, and support for four to six expectant mothers with high-risk pregnancies and their support persons in a group setting, facilitated by a midwife and a nurse. This is the first time this model of care is being piloted with this patient population.

Lisa Kugler, CNM, MSN, BSN, BS, Children’s Hospital of Philadelphia, Philadelphia, PA Mari-Carmen Farmer, BSN, RNC-OB, BS, Children’s Hospital of Philadelphia, Philadelphia, PA

Keywords group prenatal care high-risk pregnancy Implementation, Outcomes, and Evaluation psychosocial support Five cohorts, each including four to six women and Centering Pregnancy their support persons, received their last 4 weeks fetal anomalies

of prenatal care within the group setting. Evaluations have been conducted using questionnaires and focus groups. Results indicated a high level of patient satisfaction with the model, increased encounter time with providers, and greater ability to access support in response to changes and setbacks.

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Implications for Nursing Practice Nurses are positioned to play key roles in group prenatal care as facilitators and providers. Group prenatal care provides a unique opportunity for the bedside nurse and the advance practice nurse

to partner in the delivery of care and the evaluation and research of this innovative practice. The framework of group prenatal care allows for interdisciplinary collaboration in the delivery of highquality, evidence-based patient care.

Promoting Normal Physiologic Birth through Partnership with Consumers, Providers, and Hospitals MaryJane Lewitt, PhD, CNM, APRN, Emory University College of Nursing, Atlanta, GA Keywords evidence-based maternity care nursing practice healthy birth perinatal quality measures

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Purpose for the Program ncreasing access to care that promotes and supports physiologic birth is a major national strategy for achieving high-quality, high-value, maternity care. The multidisciplinary Normal Birth Task Force works to engage consumers and professionals in efforts to promote full-term physiologic childbirth.

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Proposed Change Quality improvement efforts that aim to reduce cesarean births and improve overall birth outcomes will require participation from various disciplines: nurses, nurse–midwives, physicians, doulas, hospital administration, and quality managers. The Normal Birth Task Force was created in response to the need for strategies to increase access to normal, physiologic childbirth. The Normal Birth Task force created a three-stage approach to expanding implementation of evidence-based maternity care. Implementation, Outcomes, and Evaluation Collective public interest in high quality, safe, and effective health care has drawn attention to the procedure-intensive birth culture in the United States. The American College of Nurse–Midwives (ACNM) Normal Birth Task Force was created in 2012 in response to the need for strategies to increase women’s access to normal, physiologic childbirth and to support evidence-based

maternity care. The group evaluated data, created implementation plans, and communicated processes to consumers, providers, and hospital systems. The task force created a consumer education and engagement document, a policy and quality focused document aimed at facilitylevel decision makers and a toolkit that allowed health care providers to access materials to support change, increase implementation, and gather quality metrics that support normal, physiologic birth through implementation of evidence-based maternity care. Implementation of these strategies is in effect at various facilities across the United States. Quality and safety reporting indicators have been implemented for perinatal care. Obstetric interventions are overused and misused in many settings, whereas beneficial practices that promote optimal maternal and newborn health are often underused. The Joint Commission’s Perinatal Core Measures are amenable to improvement by implementing physiologic care with demonstrable results. Implications for Nursing Practice The Normal Birth Task Force created tools for the implementation of various strategies aimed at achieving tangible outcomes for consumers, professionals, and facilities. These tools can be implemented immediately by nurses to increase the support of evidence-based maternity care at their facilities.

Innovative Programs to Enhance the Experience for the Obstetric Patient Debbie Biffle, BS, RNC, Abbott Northwestern Hospital, Bloomington, MN Kelsi Le, BSN, Abbott Northwestern Hospital, Eagan, MN

Purpose for the Program mprovement of the birth experience to focus on providing nurses additional tools and interventions for a wide range of comfort modalities for obstetric patients in the antepartum period, labor, and postpartum periods.

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Proposed Change To improve the woman’s experience, the following innovative changes were put into place:

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(a) a comfort menu used by women to control their pain management choices, (b) aromatherapy that is available to all women with education and rationale for use, (c) acupressure for women in labor, (d) a water birth and water therapy program for women in labor, (e) guided imagery for women during labor and the antepartum and postpartum periods at the bedside, (f) evidence-based education related to positions for labor, (g) videos about

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labor pain for women to view before hospitalization and when admitted. Implementation, Outcomes, and Evaluation Implementation of these projects occurred during several years. The Patient Experience team began by reviewing patient satisfaction outcome data and comments from the patient population. They also interviewed staff to determine which tools they would need to improve the patient’s experience. Implementation was performed with a variety of classroom education, hands-on demonstrations, and development of the actual tools to

use with the patients. The outcomes we utilized to assess the success of each tool included patient rounding and review of patient satisfaction data. We have seen a significant increase in pain management scores since the implementation of these initiatives. Implications for Nursing Practice Nurses have a great effect on the comfort of the patients that they serve. Through the evaluation of the evidence and our patient experience scores we have developed a program that focuses on comfort with multiple modalities.

Keywords comfort pain management patient experience

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A Multidisciplinary Team Approach to Management of Postpartum Hemorrhage Purpose for the Program his hospital is a teaching facility with a diverse population of families. It is the only free-standing women’s hospital in the state and averages 6200 births per year. Despite being a groundbreaker in many ways, the rate of postpartum hemorrhage (PPH) was almost equal to the state and national averages. There was no standardized approach to the management of PPH, and with an increasing urgency to improve PPH outcomes, the nursing staff made the decision to make a change. The goals were to develop a PPH protocol, decrease the rate of PPH-related transfusions, and decrease the number of PPH-related adverse outcomes such as peripartum hysterectomies. When any of these events occur, often the length of stay increases as well.

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Proposed Change To implement a culture of safety and enhance interdepartmental teamwork. A team approach was needed to develop and utilize a standardized protocol. Although historically physicians and nurses did not participate in education together, educating all members of the health care team at the same time was essential. Implementation, Outcomes, and Evaluation A focused, multidisciplinary team representing every clinical department in the hospital formed a

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PPH committee and was facilitated by nursing staff. Each member of the team took ownership by using the plan, do, check, act (PDCA) quality improvement methodology. The protocol was developed; didactic learning and 87 simulation classes took place with participation from more than 83% of the entire staff and physicians.

Jenny C. Clapp, MSN, RNC-OB, Cone Health Women’s Hospital, Greensboro, NC

Keywords postpartum hemorrhage multidisciplinary team approach The rate of PPH-related transfusions decreased simulation

from 3.5% in 2009 to 2012 to 2.8% in 2014. Peripartum hysterectomies decreased from an average of 4.1/year in 2009 to 2012 to two in 2013 and two in 2014 year to date. Before participating in the simulation, the mean confidence level in identifying and managing a PPH was 2.6 (N = 307) on a Likert-type scale (1 = not confident at all, 4 = very confident). One month after the simulation, 90% of the participants said they felt either confident or very confident.

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Implications for Nursing Practice Nurses can be the change agents in an environment that has not embraced a true team approach, but it takes well-coordinated effort and physician champions. Nurses at the bedside can be empowered to initiate evidence-based practice approaches to improve outcomes and the overall quality of life for mothers and their families.

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Clapp, J. C.

Proceedings of the 2015 AWHONN Convention

Empowering Nurses to help Reduce the Rate of Primary Cesarean Births Amy W. Prince, RNC-OB, MSN-Ed., Bon Secours Health System-St. Francis Medical Center, Midlothian, VA Emily Armstrong, BSN, Bon Secours St Francis Medical Center, Midlothian, VA Keywords primary cesarean birth improving outcomes safe prevention

Childbearing Poster Presentation

Purpose for the Program esarean birth has come to the forefront of discussion by The Joint Commission, Association of Women’s Health, Obstetric and Neonatal Nurses, and American College of Obstetricians and Gynecologists because of its effect on the increased risk of maternal morbidity. Of particular focus is the primary cesarean. A program to facilitate the safe prevention of the primary cesarean will optimize patient outcomes, decrease hospital length of stays, and decrease the rate of repeat cesarean births.

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Proposed Change To promote positive patient outcomes and reduce the rate of primary cesarean births by incorporating a collaborative effort between leaders, nurses, and health care providers. A change in culture will directly affect outcomes. The change encompasses hard-stop guidelines for early elective inductions, nursing education for techniques to manage various stages of labor, and the use of innovative equipment to optimize movement for the woman in labor. Implementation, Outcomes, and Evaluation The unit implemented hard-stop guidelines to prevent early elective inductions of labor, the use of wireless fetal monitoring to encourage mobility in

labor, the use of labor techniques to optimize vaginal births, and education for staff on the management of the stages of labor. As a collaborative effort with health care providers, we decreased the early elective induction rate to 0% within the first year. Leadership supported the opening of a triage unit to promote a decrease in triage hours, which facilitated prompt discharge for those patients who were not in labor. Program evaluation occurs during a monthly Perinatal Collaborative meeting, which includes leaders, nurses, and health care providers to discuss progress and process improvements. The team is dedicated and focused on optimizing patient outcomes and decreasing the rate of primary cesarean births. Implications for Nursing Practice By empowering and educating nurses on their active involvement in the process, we reduced the rate of primary cesarean birth by 12% from fiscal year 2013 to fiscal year 2014. In August 2014, the unit announced 208 deliveries with a primary cesarean rate of 9%. The implementation of the wireless fetal monitoring system, labor techniques, and the childbirth education conference was directly correlated with a decrease in the rate of primary cesarean birth.

Collaborating to Create a Comprehensive Neonatal Resuscitation Form Newborn Care

Bonnie Hibbs, BSN, RNC, Baptist Health Louisville, Louisville, KY Mary Ann Bell, BSN, RNC, Baptist Health Louisville, Louisville, KY

Purpose for the Program igh-quality care of the newborn at birth is critically important in obstetrics. To assess response to newborns who require extra assistance at birth, a newborn code review committee was formed in July 2012. Newborn resuscitation documentation was audited for 3 months, and it was determined the current form was a barrier to accurate documentation and care. Of the 16 indicators audited, documentation was found to be 0% to 67% complete in seven categories. The code committee searched the literature, Internet, and area hospitals to find a better documentation form. Forms found were either equal to or less comprehensive than the current form.

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Proposed Change To create a new form that follows the guidelines of the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program to increase documentation adherence and provide documentation prompts to perform correct actions during a newborn code. The American Heart Association (AHA) “Get with the Guidelines” neonatal resuscitation form was used as a starting point. Content was added and removed based on team experience with newborn codes and AAP guidelines. Implementation, Outcomes, and Evaluation The new form, completed in October 2012, was taken to delivery team nurses and neonatologists for review. After suggested changes were made,

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the code team approved the final form, and staff members involved in newborn resuscitation were taught to use it. Health care providers began using the new form in May 2013. Neonatal resuscitation records from July through October 2013 were reviewed to identify trends and improvements after implementation of the new form. Of 16 categories audited, adherence scores increased from 88% to 100%. Nursing and medical staff expressed satisfaction and acceptance of the new form, noting ease of use and guidance through

code documentation and prompts for needed actions. Audits continue to show improvement in documentation after the implementation of the Keywords neonatal resuscitation form form. documentation of neonatal code newborn code review team Implications for Nursing Practice Teams should review current neonatal resuscita- Poster Presentation tion forms for documentation accuracy and adherence. Revisions may be necessary to help guide practitioners through resuscitation and assist with accurate documentation.

Telemedicine for Neonatal Resuscitation Purpose for the Program aintaining high levels of readiness for neonatal resuscitation in settings with lowrisk maternity services is challenging. Use of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) algorithm is a community standard in the United States; however, training is often only required every 2 years, and few staff receive enough exposure to these critical events to be proficient at timely implementation of the algorithm and advanced procedures such as umbilical vein access and endotracheal intubation. Birth centers may not have a practitioner immediately available to lead neonatal resuscitation. Even when staff is trained in advanced procedures, the skills needed for full resuscitation are not performed regularly, and low levels of comfort with these skills are reported. Additionally, task saturation occurs when team leaders are expected to perform advanced procedures while leading the resuscitation team. There are reports that errors in neonatal resuscitation continue to occur related to team skill level, including problems with effective training, muscle memory building, communication, and task saturation. At sites where there is limited exposure to emergency events because of low volumes of high-risk deliveries, staff may never build up the experience needed to efficiently and effectively resuscitate a premature or ill newborn.

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Proposed Change To develop a Telemedicine Resuscitation Program that links a remote NRP leader in an neonatal intensive care unit (NICU) to low-risk maternity centers. There is evidence to support the value of handsfree leadership to help prevent task saturation and the benefits of communication to promote patient safety.

Implementation, Outcomes, and Evaluation We implemented the program between a LevelIV NICU and three Level-I nursery sites within our system. Every patient event was tracked, debriefed, and analyzed. Our outcomes data show an improvement in team support and improved communication, which have led to more effective, consistent adherence to NRP principles and a positive effect on time-to-transfer initiation and time-to-initiation of neuroprotective cooling.

Pat Scheans, DNP, NNP-BC, Legacy Health, Portland, OR Lori McElwain, BSN, RNC-OB, Legacy Good Samaritan Medical Center, Portland, OR Keywords telemedicine NRP resuscitation

Newborn Care Poster Presentation

Implications for Nursing Practice This novel use of telemedicine for remote neonatal resuscitation leadership could support perinatal teams at community hospitals by tertiary care centers. Furthermore, it could improve medical care in remote and low-resource birthing centers throughout the United States and around the world.

Preventing Newborn Falls Purpose for the Program n fiscal year 2012, six newborn falls were reported at Anne Arundel Medical Center (AAMC). As a result of this disturbing trend, the Mother/Baby Quality Council developed a Newborn Falls Prevention Task Force. The goals of the task force were to identify factors associated with newborn falls and make recommendations to reduce newborn falls.

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Proposed Change After reviewing the literature, examining and analyzing the information related to the falls in our hospital, and attending the 2013 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) convention, we developed a plan which included the following: (a) create the expectation that nurses and patient care technicians discuss newborn falls prevention with parents at

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Mary M. Hantske, MSN, RNC-OB, Anne Arundel Medical Center, Annapolis, MD Keywords prevention of newborn falls

Newborn Care Poster Presentation

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Hantske, M. M.

Proceedings of the 2015 AWHONN Convention

least once every 12-hour shift; (b) develop patient handouts related to infant safety, including falls prevention; (c) create signage for patient rooms to remind parents not to fall asleep with newborns in their beds; (d) create signage for postpartum units indicating the number of days since the last newborn fall; (e) discuss newborn falls at staff meetings and quality council meetings. We decided not to implement hourly rounding because one of our newborns was dropped by the mother within 20 minutes of the nurse leaving the room. Implementation, Outcomes, and Evaluation Staff members were kept informed of the new program and our progress through e-mails and

staff meetings. In fiscal year 2013, the number of falls reported was two, which was before our program was fully implemented in June 2013. In fiscal year 2014, we had one newborn fall. So far in fiscal year 2015, we have not had any newborn falls.

Implications for Nursing Practice On a mother/infant unit where newborns stay with their mothers for approximately 23 hours per day, a newborn falls prevention program that focuses on parent, family, and staff education can be effective in reducing newborn falls.

Decreasing Newborn Readmissions for Hyperbilirubinemia Beverly VanderWal, MN, RNC-OB, Spectrum Health, Butterworth Hospital, Grand Rapids, MI

Purpose for the Program yperbilirubinemia is the most common indication for hospital readmission of term and late preterm infants. In reviewing our performance, Charmaine L. Kyle, MSN, RN, we identified a 12-month rolling readmission rate EFM-C, Spectrum Health, of 2.43%, which was greater than the 1.50% Grand Rapids, MI benchmark of other large teaching hospitals. Analysis of our data revealed that 25% of newborn Keywords newborn jaundice readmissions were for hyperbilirubinemia. In an breastfeeding effort to reduce readmission rates, we identified readmission opportunities to update and standardize assessment and management of hyperbilirubinemia.

Newborn Care Poster Presentation

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Proposed Change Our previous practice was to perform a transcutaneous bilirubin test at age 30 hours and to notify the infant care provider only if the infant fell into the high-risk zone (95th percentile per the Bhutani nomogram). Subsequent testing and treatment was determined by the individual care provider, and there were no standard nursing interventions. A multidisciplinary task force was established to develop and implement an algorithm based on current evidence that focused on assessment, early identification of at-risk infants, early implementation of interventions, and consistent outpatient management. Simultaneously with this work our facility was implementing the 10 Steps to Successful Breastfeeding in preparation for achieving Baby Friendly Hospital designation. The task force hoped to take advantage of the work in progress to

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support breastfeeding because a major risk factor for hyperbilirubinemia is inadequate breastfeeding. Implementation, Outcomes, and Evaluation We utilized the plan, do, study, act (PDSA) model to develop and implement the new algorithm. After four cycles with draft algorithms, we agreed on the final version. Nurses and physicians were educated on the algorithm, and it was implemented throughout the newborn service. Physician task force members also educated their peers on criteria for readmission and use of the online BiliTool to standardize treatment. The rolling 12-month readmission rate in July 2014 was 1.89% which represents a 23% decrease. In evaluating our successful practice changes, we anticipate a continued decrease in the rolling 12-month rate. The task force continues to review monthly data and analyze the effectiveness of interventions. Implications for Nursing Practice Nurses manage the care of hospitalized newborns and are responsible for assessing newborns, collaborating with health care providers, and implementing interventions, especially those that facilitate successful breastfeeding. The use of this algorithm standardizes practice to ensure that every infant receives appropriate evaluation of risk and intervention to avoid significant hyperbilirubinemia.

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Implementing Routing Skin-to-Skin Contact in the Operating Room Purpose for the Program kin-to-skin (STS) contact immediately after birth has been proved to provide benefits to the mother and newborn, including improved temperature regulation, reduced rates of postpartum hemorrhage, and promotion of bonding and early breastfeeding. Before the implementation of our STS practice in the operating room (OR), mothers who had cesarean births and their newborns were not able to enjoy these benefits.

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Proposed Change Mothers who gave birth by cesarean at our community hospital wanted the opportunity to experience STS in the OR and to minimize the delay in seeing and holding their newborns after birth. Their concerns were heard by the nurses and physicians and discussion began on how this practice could possibly work in our small unit and OR. Planning and communication were key to realizing this evidence-based practice. Implementation, Outcomes, and Evaluation A small group of nurses who had a strong interest in making this practice a reality met and reviewed

research on the topic and discussed how we could accomplish this practice with a small staff. Discussion and planning with the pediatricians, obstetric (OB) physicians, anesthesiologists, and the rest of the nursery staff took place. The mothers were educated on the benefits of STS and how this would take place in the OR. Soon we implemented the procedure and brought the first newborn from delivery to the warmer (to be quickly dried off) and then to the mother’s chest for STS. The goal was to keep the newborn STS for 30 minutes if the mother was able. Documentation of the length of STS was recorded in the newborn’s record. Many mothers who experienced prior cesareans without STS stated how much more meaningful the current experience was.

Kim Kenyon-Berry, MSed, BSN, RNC, Saratoga Hospital, Saratoga Springs, NY Cory Seymour, MSN, BSN, Saratoga Hospital, Saratoga Springs, NY Keywords skin-to-skin operating room communication planning

Newborn Care Poster Presentation

Implications for Nursing Practice Women and newborns can now take advantage of immediate STS contact in the OR, which is the best first step for early well-being and stabilization. This early contact promotes bonding, breastfeeding, and other birth recovery benefits.

Improving the Quality of a Newborn Screening Program at an Academic Medical Center Purpose for the Program o describe a program to improve compliance rates for completion of mandatory newborn screening at a large academic medical center.

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Proposed Change A comprehensive newborn screening program, including elements for metabolic, hearing, and critical congenital heart disease, was implemented. Program improvement efforts focused on a transition from a decentralized process to a centralized process focused on a designated team of testers under the leadership of a newborn screening coordinator (NSC). Implementation, Outcomes, and Evaluation Implementation of this program coincided with commencement of a new computerized data entry system at the state level. All members of the screening team were trained on the various screening processes they were to perform. Consistent operating procedures were developed to ensure standardization of the screening pro-

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cess for all infants. Nursing staff and pediatricians were educated on the changes to the screening process. Compliance reports from the state are monitored by the NSC and the patient service manager. The NSC reports to the Well Newborn Nursery Committee, the Perinatal Committee, and the Obstetrics Operations Committee as to the hurdles, progress, and outcomes from the screening program. The program is ongoing with regular assessment and evaluation of processes and outcomes, which drives quality improvement. Implications for Nursing Practice Nurses must understand their state mandated roles in the newborn screening process. A NSC remains current regarding the laws that govern the process and educates nurses as changes occur. A designated team of testers can provide standardized and knowledgeable education to parents. The described newborn screening program improves compliance with state newborn screening requirements.

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Elizabeth O’Mara, BSN, RN, CNML, AONE Nurse Fellow, Yale–New Haven Hospital, New Haven, CT Cheryl Raab, BSN, RNC-OB, C-EFM, Yale–New Haven Health System, New Haven, CT Keywords newborn screening neonatal screening metabolic screening critical congenital heart disease hearing screening nursing practice

Newborn Care Poster Presentation

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O’Mara, E. and Raab, C.

Proceedings of the 2015 AWHONN Convention

Best Practices for Transitioning from the Birthing Unit to the Mother–Infant Unit Purpose for the Program s we sought to obtain Baby Friendly Hospital designation, we had the opportunity to evaluate our practices in transitioning women from the birthing unit to the mother/infant unit. We disChristie Forward, BSN, covered two critical practices that were suboptiRNC-MNN, Hospital of the mal and lacked supporting evidence for best paUniversity of Pennsylvania, tient outcomes: nurse-to-nurse hand-off and the Philadelphia, PA mother/infant admission process. To improve paMaggie Power, BSN, RNC-OB, tient outcomes and satisfaction, our team recognized that these two practices were interdepenHospital of the University of Pennsylvania, Philadelphia, PA dent and required a synergistic problem solving approach for change. Keywords Marianne D. Bittle, MSN, RNC-OB, Hospital of the University of Pennsylvania, Philadelphia, PA

postpartum shared governance bedside hand-off rooming in transitions

Newborn Care Poster Presentation

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Proposed Change The traditional practice of telephone hand-off was time consuming, inefficient for nurses with multiple demands, did not engage the woman and family, and was not conducive to a seamless transition from one unit to another. Importantly, this transition process, which routinely separated well newborns from healthy postpartum mothers for admission care, had the potential to interfere with bonding and breastfeeding success. An interprofessional team led by the councils of the birthing and mother/infant units recognized the relationship between these processes and the need to align them with Baby Friendly and family-centered care practices. They developed, implemented, and evaluated an evidence-based practice project that transitioned the mother/infant dyad from the birthing unit to the postpartum room

for admission care while integrating face-to-face interprofessional bedside hand-off. Implementation, Outcomes, and Evaluation The councils were instrumental in identifying, developing, and evaluating these practice changes. Before piloting, women and nurses were surveyed regarding the current processes and then again after implementation. During the pilot period, more than 130 mother/infant dyads were transitioned directly to the postpartum room for admission care with no adverse outcomes related to the process. In addition, unit council representatives also collaborated with provider stakeholders to develop and pilot the interprofessional face-to-face bedside hand-off process. They developed a notification strategy and utilized technology to provide consistent information among team members. Since full implementation of these practices, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores have shown significant improvement as well as breastfeeding initiation and rooming in rates. Implications for Nursing Practice The benefit of a seamless transition process that allows mothers and newborns to stay together from birth until discharge is well documented. Nurses have a responsibility to examine current practices, move away from nurse-centric traditions, and initiate those that move toward evidence-based, patient-centric best practices.

Transitioning to Couplet Care Cindy S. Baker, MSN, RNC-OB, C-EFM, CCE, St. Francis Hospital, Charleston, SC Stephanie T. Naumann, BSN, RN, St. Francis Hospital, Charleston, SC

Purpose for the Program y sharing our challenges, adjustments, and successes, at St. Francis Hospital in Charleston, South Carolina, we hope to encourage other hospitals to implement the evidence-based practice of couplet care.

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Proposed Change To utilize best practice in the nursing care of mothers and newborns while increasing staff teamwork, nurse satisfaction, and patient satisfaction. Implementation, Outcomes, and Evaluation To transition from traditional maternity care to couplet care, a Family Centered Care Commit-

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tee (FCC) of staff nurses, physicians, and nursing leaders was created in March 2013. This multidiscipline committee was a venue where common misconceptions, resistance, and patient/employee satisfaction were discussed as well as how to change a culture based on history and tradition. Also discussed were the evidencebased research and best practices currently used in maternity care. A plan for providing staff with current research, didactic education, assessment/care classes, and cross training was devised and implemented by the team. Surveys for the staff were given at several intervals during the transition to keep staff engaged and part of the change process.

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Since implementation in April 2014, patient satisfaction has increased, and there also has been a slight increase in employee satisfaction. This is still a project in continuous process improvement. More surveys will be distributed to staff in September 2014, December 2014, February 2015, and April 2015 to gauge staff satisfaction and feedback for improvement with the change to couplet care. Transitioning to couplet care demands a change in practice for the nursing staff and physicians. By implementing couplet care, exposure of frailties and obstacles were success-

fully addressed and have been identified and treated. Implications for Nursing Practice The transition to couplet care from traditional maternity care can be fraught with challenges. However, if proper planning and education are undertaken, couplet care that is rewarding to staff and patients can be achieved. Couplet care has been shown to increase exclusive breastfeeding rates, decrease newborn admissions to higher level care, and increase patient satisfaction.

Keywords couplet care family-centered care change theory mother/infant care family-centered maternity care

Newborn Care Poster Presentation

Postpartum Unit Modifies Delivery of Care to Enhance Readiness Purpose for the Program ew mothers and their families have multiple learning needs, starting in the prenatal period and progressing through labor into the postpartum phase. Nurses are accountable for facilitating the necessary learning by identifying and addressing the specific needs of the family unit. Before discharge it is the responsibility of the nurse and health care team to ensure that the patient and family receive consistent and reliable information. Recognizing an opportunity to improve patient perception of readiness for discharge, our mother/infant unit decided to revise our care delivery model.

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Proposed Change Modifications to practice included development of a blue discharge folder to be originated upon admission and serve as a living document to record education and follow the woman throughout her stay. This folder served as a reference for the interprofessional team as well as a continuous resource for home. Additionally by incorporating a designated discharge nurse, providing an in-patient daily Baby Care Class, developing and utilizing a Postpartum Resource Reference Guide, and incorporating specific medication use/side effect information cards, efforts were established to reinforce patient education throughout the hospital stay. Additional resources

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were implemented for women after discharge, including 24-hour help-lines, follow-up phone calls, home health visits, breastfeeding support groups, and infant cardiopulmonary resuscitation (CPR) education. Implementation, Outcomes, and Evaluation For a 12-month period we have tracked patient responses to the following specific Press Ganey Patient Satisfaction Survey questions. These data were used to measure the effectiveness of the modifications implemented. Specific questions and corresponding results included Staff described possible side effects of their medicine (preintervention 55, postintervention 73.7); Nurses and physicians explained things in a way patients could understand (preintervention 84.2 postintervention 91.50); Patients received information in writing about symptoms or health problems to look out for after leaving the hospital (preintervention 87.3, postintervention 98.3); and Extent to which you felt ready for discharge (preintervention 85.9, postintervention 92.7). The patient response has been overwhelmingly positive to these changes as evidenced by patient comments.

Dona L. Meringer, MSN, RNC-MNN, HBN-BC, The Valley Hospital, Ridgewood, NJ Beth McGovern, MSN, RNC-OB, The Valley Hospital, Ridgewood, NJ Kate Amin, BSN, RNC-MNN, The Valley Hospital, Ridgewood, NJ Keywords discharge postpartum infant care

Newborn Care Poster Presentation

Implications for Nursing Practice By providing consistent and individualized education to all patients, our unit was able to provide thorough and accurate discharge education and to increase patient readiness for discharge.

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Meringer, D. L., McGovern, B., and Amin, K.

I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

Education Program Improves Knowledge of Maternity Staff Regarding Breastfeeding Marjorie S. (Susie) Amick, Purpose for the Program MSN, RN, IBCLC, LCCE, East ouisiana (LA) breastfeeding rates are among Jefferson General Hospital, the lowest in the United States, and asMetairie, LA

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Keywords breastfeeding evidence-based practice maternity staff knowledge

Newborn Care Poster Presentation

sociated infant mortality and morbidity rates are among the highest. To increase the knowledge of maternity nursing staff regarding breastfeeding and improve attitudes towards implementing evidence-based maternity practices that facilitate breastfeeding, a six contact-hour program promoting LA’s breastfeeding initiative, The Guided Infant Feeding Techniques (GIFT) was developed. The 10 steps of GIFT are based on the Baby Friendly USA Ten Steps to Successful Breastfeeding with maternity nursing staff education identified as a critical component.

Proposed Change To increase staff knowledge and improve attitudes and self-efficacy of nurses in implementing the criteria for GIFT hospital certification, which is a stepping stone to Baby Friendly designation. Implementation, Outcomes, and Evaluation The GIFT nursing staff program “Promoting Evidence-Based Breastfeeding Support in Louisiana: The GIFT” was presented to 1086 participants in 35 hospitals across LA from November 2008 to February 2012. Pretests and identical posttests were provided. Posttest scores were significantly higher after each session in each program (p < .01). The mean score of each LA public health region posttest was greater than 95%, which is an increase of more

than 25% from pretest scores. Participant evaluations identified positive ratings for the program having increased knowledge, changed a skill or an attitude, enhanced practice performance, and improved customer service. Descriptive analysis of responses to open-ended evaluation statements indicated increased intention to implement strategies promoting evidence-based maternity practices. Within 30 months after the program, the number of GIFT-certified hospitals had increased from nine to 24 of the 53 maternity hospitals in Louisiana. Louisiana breastfeeding rates and national rankings by the Centers for Disease Control and Prevention (CDC) Breastfeeding Report card have increased from 2007 (year before the education program) to 2013 (year after the education program ended) although they remain (in four of five Healthy People 2020 goal categories) in the lowest quartile of the United States. Implications for Nursing Practice Program strengths, as reported by participants, include convenience and minimal expense in time and money. Programs repeated in each region allow increased same-hospital staff attendance. The development of webinar programs and train-thetrainer programs are being explored as future options. Breastfeeding programs such as the GIFT nursing staff education program will potentially increase knowledge, intention, and advocacy for increased implementation of evidence-based maternity practices that increase breastfeeding rates to improve outcomes for infants and women.

Accurate Weight Measurement for Neonates Mary Otero, BSN, RN, NE-BC, Purpose for the Program Bon Secours St. Mary’s o improve patient outcomes and quality of Hospital, Richmond, VA

borns. This makes it extremely important for health care professionals to have an accurate weight to establish the best plan of care.

Michelle Mayton, RNC-MNN, Bon Secours St. Mary’s Hospital, Richmond, VA

Improving rates of breastfeeding exclusivity and duration is a focus of the mother/infant unit and part of attaining Baby Friendly status. Nurses on the mother/infant unit identified increased supplementation being ordered because of weight loss. Every infant regardless of birth time was weighed on the night shift. Literature was collected to identify risk factors that could influence weight loss in newborns. A decision was made to change practice to all newborns being weighed every 24 hours from delivery time. Practice change can always

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Keywords Baby Friendly supplementation newborn weight breastfeeding

Newborn Care Poster Presentation

care by assessing accurate weight loss of newborns who are predominantly breastfed.

Proposed Change To change practice to have all newborns weighed every 24 hours from time of birth at the hospital until discharge. Implementation, Outcomes, and Evaluation Excess weight loss is common in term breastfed newborns. There are several modifiable risk factors that can affect the amount of weight loss that can occur in the first 24 to 48 hours of life in new-

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be challenging. Nurse leaders met with physician leaders to elicit their support. Although there were some reservations about not always having weights at rounding, they began to support the change. Nurses were concerned about the added workload on all shifts. Feedback was encouraged from all staff to make this transition as smooth as possible. An additional scale was obtained so a newborn could be weighed in the woman’s room. Physicians and families verbalize satisfaction with the new practice. The accurate weights allow physicians to see a better picture of the newborn’s weight loss over a period of time. Data regarding rates of exclusive breastfeeding are in the range of 80% to 90% since 2014. Lactation data indi-

cate a decrease in supplementation for weight loss. Implications for Nursing Practice Before May 6, 2013, the nursing staff would weigh newborns at any time during the night shift. The initiated practice change forces all nurses to track birth times and ensures that infants are weighed at this time. The education and data given from this practice change also empowered the nurses to have conversations with physicians concerning supplementation and when it is necessary. Nurses verbalize a better understanding of newborn weight loss and feel they are now documenting accurate weights.

The Use of Pasteurized Donor Human Milk for Late Preterm Infant Supplementation Purpose for the Program ate preterm infants (LPIs) are born between 34 and 36 6/7 weeks of gestation. They comprise a unique population requiring enhanced awareness of transition, infection, nutrition, discharge readiness, and parent education that needs to begin shortly after birth. At Sharp Mary Birch Hospital for Women and Newborns we have on average of 60 to 80 late preterm births per month. Approximately 50% of those newborns go to the NICU, whereas the other half are cared for in the postpartum unit. Caring for LPIs in a postpartum setting comes with its own set of challenges. Although we had specific late-preterm guidelines in our newborn guidelines of care, policies and order sets were all primarily developed with the term infant in mind, which caused inconsistencies in the care provided and on occasion led to hospital readmission of the late-preterm infant.

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Proposed Change To develop more targeted guidelines, clear late preterm orders, streamlined supplementation protocols, and discharge criteria that are specific to late preterm infants. Implementation, Outcomes, and Evaluation The project had several phases. Our team completed the following: We developed educational

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materials for the nurses, families and physicians to raise awareness of the unique circumstances surrounding the LPI. We revised policies and procedures relating to newborn care, feeding, and supplementation of infants to reflect best practice for the LPI. We created a separate supplementation policy for LPIs and developed individual feeding management guidelines for LPIs with optional donor milk supplementation. We edited the Nursing Guidelines of Care to include more detailed information relating to LPIs. We restructured the newborn admission orders to include specific orders to address the unique nature of LPIs. Newborn orders now have a nested late-preterm newborn orders subset.

Monika Lanciers, BSN, RNC-MNN, CLE, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Mary Ann Jones, RN, BSN, IBCLC, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Keywords late preterm supplemental feeding pasteurized donor human milk decreased readmission

Newborn Care Poster Presentation Implications for Nursing Practice Implementing these specific interventions had measurable positive effects on the late preterm newborn population at Sharp Mary Birch. Our utilization of donor milk was well received by staff and patients. Readmission rates to the NICU have steadily decreased. As a result of the improved care provided, the readmission rate of LPIs to the NICU had decreased 40% in the past 24 months based on the equivalent ratios 0.3 to 0.18 = 100% to 60%.

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Lanciers, M. and Jones, M. A.

Proceedings of the 2015 AWHONN Convention

Implementation of Delayed Cord Clamping Elizabeth Zehner, RN, Women’s Health Pavilion, Clinical Ladder III, Beebe Healthcare, Lewes, DE Keywords higher Apgar scores stem cells murmurs skin perfusion infant temperature

Purpose for the Program o disseminate information that was learned at the national AWHONN Conference in June 2014.

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Implementation, Outcomes, and Evaluation To provide support with the implementation, which started in August 2014, staff, obstetric providers, and pediatric providers were educated about the benefits of delayed cord clamping.

Proposed Change To overcome barriers by educating staff and health care providers with evidence-based research and implementing delayed cord clamping.

Implications for Nursing Practice The change in practice pattern to allow delayed cord clamping allowed for placental transfusion of the newborn’s blood at birth.

Newborn Care Poster Presentation

Changing Breastfeeding Culture through Staff Training Melissa A. Moreau, FNP, Women & Infants Hospital, Providence, RI Keywords breastfeeding Baby Friendly peer education

Newborn Care Poster Presentation

Purpose for the Program reastfeeding provides protection against a multitude of illnesses for the mother and infant. Implementation of the World Health Organization’s Ten Steps to Successful Breastfeeding has been proved to increase breastfeeding rates. The purpose of this program was to develop a comprehensive curriculum to provide knowledge and skills to assist staff in implementing practices to support breastfeeding

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Proposed Change Women & Infants Hospital (WIH) is known as a premier hospital for women and newborns with approximately 8400 births per year. The Centers for Disease Control and Prevention reported that Rhode Island ranks 34th nationally and has the lowest breastfeeding rates in New England. Because 73% of infants born in Rhode Island are born at WIH, it was clear that we needed to increase our hospital breastfeeding rate. We proposed implementing the Ten Steps to Successful Breastfeeding in our institution. Staff believed that current non-evidence-based practices where best and struggled over the fear of creating guilt for new mothers. It was clear that staff needed knowledge, practice in counseling skills, and support in shifting practices. Implementation, Outcomes, and Evaluation The education model developed consisted of multiple layers to allow for different learning styles and

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staff comfort level. The initial education consisted of computerized modules outlining the maternity care practices that support breastfeeding. Once completed, the staff attended a simulation day. The day consisted of lecture, hands-on skills sessions, and simulation around counseling parents on feeding decisions, supplementation, and rooming in. Simulation allowed for practice as well as detailed discussion around difficulties and best practices. In addition, the breastfeeding champions model was created. In this model, staff nurses were identified as unit champions. Champions from across the hospital meet monthly to discuss unit and interdepartmental barriers. The champions have been responsible for policy changes, planning and running skills days, unit education, modeling, and peer support. Since the implementation of this model we have seen a steady increase in rates of all the maternity care practices outlined in The Ten Steps to Successful Breastfeeding. Overall, we have seen a shift in the culture of our staff, which has an increased comfort level in implementing practices and counseling the new parent.

Implications for Nursing Practice Staff often struggle to incorporate new practices into the care they routinely provide. This model can be adapted to meet the needs of staff undergoing change or instituting new practices.

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Development of a Collaborative Partnership to Improve Communication and Access to Obstetric and Pediatric Patient Care Information for High-Risk Referrals Deborah A. Gingras, MS, RN, Purpose for the Program Hartford Hospital, Hartford, CT n a multihospital, high-risk obstetric (OB) serKeywords perinatal high-risk referral communication access

Newborn Care Poster Presentation

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vice with 3600 births annually, coordinating high-risk consultations and having those consults available for review by more than 150 OB and pediatric providers in a semicomputerized system has presented many challenges. This program was developed to surmount the challenges of identifying high-risk mothers and newborns, making patient care information available to OB and pediatric providers in a timely manner, and spanning the gaps created by two different health care organizations caring for obstetric and neonatal patients.

Proposed Change An interdisciplinary task force of obstetric, pediatric, nursing, and administrative support staff met to discuss the issues related to identifying referred high-risk newborns, communicating the plan of care and expected delivery dates, and making all consultations regarding mother and fetus available to all providers caring for those patients. These maternal and fetal referrals are generated by the OB and pediatric providers based on criteria that require care at a tertiary obstetric and/or Level-III neonatal unit. A comprehensive plan was developed to address the gathering of patient care information, such as prenatal records, maternal/fetal medicine ultrasounds, pediatric subspecialty consults, and patient plans of care into one central, computerized document depository. This required obtaining necessary ad-

ministrative approvals at both health care organizations, having the required computer application uploaded in appropriate areas, and providing continued support for access and informational issues. Implementation, Outcomes, and Evaluation The plan was implemented in December 2013 with education being provided to the OB and pediatric providers, nursing staff, and administrative staff. Multiple venues for education and assistance were offered. The administrative approvals, Health Insurance Portability and Accountability Act (HIPPA) compliance issues and computer application work in the two health care organizations proved time consuming but were finally completed. Because those hurdles were surmounted, the OB and pediatric providers have increased their utilization of the process and made several suggestions to further improve communication and access to patient care information. Implications for Nursing Practice Perinatal regionalization and access to tertiary levels of perinatal and neonatal care have improved outcomes and the survival rates of our mothers and newborns. The communication and collaboration fostered between these two separate health care organizations has played a key role in improving the quality of care for our obstetric and neonatal patients. This partnership between OB and neonatal staff has improved communication, improved relationships, and encouraged a new outlook on our shared patients.

Daily Rounding for Patient Safety and Nursing Satisfaction Professional Issues

Nan Ybarra, MBA, BSN, RN, NEA-BC, Texas Children’s Hospital Pavilion for Women, Houston, TX

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Purpose for the Program aps noted in knowledge regarding patients on the unit increased the number of safe staffing surveys submitted, which reported concern about assignments. Frustrations were expressed about missing or broken equipment, which resulted in increased time spent by registered nurses (RNs) searching for equipment; key patient information failing to be relayed during daily huddles; and increased length of stay in labor room due to concerns about plans of care that were not addressed. We proposed to insti-

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tute daily rounding between the bedside nurse, charge RN, unit manager, and the patient. Questions to be addressed by the bedside nurse include the following: What is your patient’s history and diagnosis? What category tracing is your fetal heart rate strip? What concerns you most about this patient? What is the plan of care for this patient? Do you feel safe with this assignment? Do you have all the equipment needed to care for patient? Questions for the patient include the following: Do you have everything you need? Do you have any concerns or questions about your plan

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I N N O VAT I V E P R O G R A M P O S T E R S

Ybarra, N.

Proceedings of the 2015 AWHONN Convention

Keywords rounding patient safety staff satisfaction

Poster Presentation

of care? Are we meeting/exceeding your expectations? Implementation, Outcomes, and Evaluation The assistant clinical director modeled the rounding process with the unit manager and charge RN to ensure that the process was fully understood. The unit manager and charge RN assumed primary responsibility of daily rounding 4 weeks after the assistant clinical director modeled the process; staff became increasingly comfortable with the new process. Some staff members were resistant. Rationale behind rounding was explained, and literature detailing the purpose and benefits of rounding was given to staff. As a result of the daily rounds, there has been a decrease in the number of safe staffing surveys submitted. There has been a decrease in the length of stay from 18

hours to 16 hours in the labor room as a result of focused discussion regarding the patient’s plan of care and an increase in patient satisfaction scores. Common patient remarks on surveys now express how the patient felt supported in their birthing decisions and informed about all processes. Increased nurse engagement and willingness to assume ownership of unit have been reported as a result of focused interaction. Implications for Nursing Practice As a result of the program, there has been increased situational awareness regarding patients with concerning conditions and/or concerning electronic fetal monitoring (EFM) tracings, increased interaction with patients, and increased direct communication by staff RN with chain of command.

Imparting Knowledge, Skill, and Confidence to Rural Nurses Carolyn A. Cook, MSN, RN-C, Purpose for the Program UC Davis Medical Center, he labor and delivery (L&D) nurse manager Sacramento, Sacramento, CA of a small community hospital contacted our

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Keywords partnership rural nurse training

Professional Issues Poster Presentation

academic medical center and requested assistance to train two medical/surgical nurses who float to the hospital’s L&D unit for the occasional birth. Located in a remote area of Northern California with a low volume of births, the hospital setting is not conducive to providing adequate L&D experience for the nurses. A partnership was proposed to better prepare these nurses to care for L&D patients.

Proposed Change Information provided by the community hospital indicated an extreme lack of resources for nurses who needed training in specialty areas. As a facility with less than 100 births per year located hours from the nearest city or major medical center, the hospital was not equipped to keep nurses current in L&D skills, knowledge, and practice. We were requested to provide a training opportunity incorporating 240 hours of didactic and practical instruction. Implementation, Outcomes, and Evaluation A contract was secured, and a training outline was developed and submitted for approval. Per UC Davis Medical Center (UCDMC) requirements, a day of hospital orientation preceded the nurses’ L&D training. This included mandatory safety training and the signing of a confidentiality agreement. When the nurses arrived on L&D,

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the Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) Perinatal Orientation and Education Program (POEP) testing was utilized as a baseline assessment of knowledge. Each nurse was assigned a master’s-prepared preceptor. The nurses received reference binders containing publications on fetal monitoring, labor and birth, postpartum care, newborn assessment, high-risk obstetrics, obstetric emergencies, and operating room procedures, as well as journal articles. They attended lectures given by the perinatal nurse educator incorporating the POEP material. An AWHONN’s Intermediate Fetal Monitoring Course (IFMC) was scheduled and conducted. Upon completion of the program, the nurses expressed tremendous gratitude to the staff and reported feeling much better prepared to care for perinatal patients. Scores on the POEP posttests increased by 32% and 44%, respectively, with an overall average score of 98.5% at the conclusion of the training. Implications for Nursing Practice The collaboration of hospitals from two very different milieus resulted in an unprecedented training opportunity for nurses caring infrequently for perinatal patients. The nurses reported an overwhelmingly positive experience. Other academic medical centers may consider developing similar programs to assist smaller hospitals in isolated areas with a lack of resources for nurse specialty training.

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An Innovative Longitudinal Educational Approach to Maternal-Child Community Health Purpose for the Program he health care environment is rapidly changing. Nurse educators must develop innovative curricula to prepare future nurses to respond to the community maternal/child health needs of an evolving health care system.

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Proposed Change Starting in 2012, University of New Mexico (UNM) graduate and undergraduate faculty partnered to provide bachelor of science in nursing (BSN) students with a longitudinal community clinical experience through the Family Health Partnership (FHP). The FHP, a faculty practice located in rural Sandoval County, NM, is a federally funded, nursemanaged practice center. Using the FHP as a clinical site, a three-term sequence of communitybased maternal/child electives were developed to engage students in activities aimed at promoting maternal/child health, preventing disease, decreasing health care disparities, and increasing access to care.

Implementation, Outcomes, and Evaluation BSN students worked with certified nurse– midwives, nurse practitioners, community health workers, and a mental health nurse practitioner to provide group prenatal care, well-child group care, and labor support; perform extended family assessments; and research community resources. Student reported benefits included building connection to a community, increased understanding of the benefits of the provision of preventative services in the community, and an increased interest in working in maternal/child community settings and/or graduate nurse midwifery programs after graduation.

Mary Wright, MSN, CNS, RNC-OB, C-EFM, University of New Mexico, Albuquerque, NM Keywords faculty partnerships maternal–child health nursing education family-health partnerships

Professional Issues Poster Presentation

Implications for Nursing Practice Partnerships between graduate and undergraduate nursing faculty and utilization of faculty practice sites can provide opportunities to provide longitudinal, innovative, clinical experiences for BSN students that increase interest in maternal–child health and community health.

Using an Acuity Tool to Maintain Productivity While Adhering to AWHONN’s Perinatal Nurse Staffing Guidelines Purpose for the Program he art of scheduling perinatal nursing staff in a small community hospital is challenging in a specialty where census and acuity are highly unpredictable. This challenge on a women and children’s (WMCH) unit is particularly complex because of five specialties: labor and delivery, postpartum/newborn, pediatrics, Level-II nursery, and cesarean birth operating room. The hospital was facing decreasing revenue, increased cost because of health care reform, fluctuations in volume, and uncompensated costs. The hospital took this opportunity to reevaluate productivity and used a health care analytics company to adopt a new productivity benchmark for all departments.

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Proposed Change The hospital’s operations excellence process utilized the Lean and Six Sigma methods to improve performance, which required that frontline staff of all levels creatively develop solutions. The WMCH department used the Lean and Six Sigma methods to determine a plan to meet this goal while main-

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taining quality care and patient satisfaction. Previously the staffing assignments were done every shift based on charge nurse predictions not on evidence. This method was unreliable and generated frustration when there were discrepancies. To staff for patient census, varying acuity levels, and maintain staffing ratios recommended by AWHONN, the department incorporated an acuity tool into the daily nursing assignment sheet. Implementation, Outcomes, and Evaluation The sheet yielded a productivity standard that clearly demonstrated whether each nurse assignment was appropriate and the unit was staffed safely every 2 hours. Charge nurses were able to make staffing decisions based on real-time data. Department leaders could look at retrospective long-range acuity and productivity data that allowed them to analyze trends and make departmental decisions. The staffing decisions were based on the acuity tool were clearly and objectively displayed to staff nurses, which allowed the nurses to feel confident with their assignments

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Dana St Laurent, BSN, Wentworth Douglass Hospital, Dover, NH Holly Santovasi, BA, Wentworth Douglass Hospital, Dover, NH Karen MacDonald, MS, RNC, NEA-BC, Wentworth Douglass Hospital, Dover, NH Keywords staffing acuity productivity

Professional Issues Poster Presentation

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St Laurent, D., Santovasi, H., and MacDonald, K.

I N N O VAT I V E P R O G R A M P O S T E R S Proceedings of the 2015 AWHONN Convention

because of the alignment with AWHONN guidelines. After 6 months of utilizing the acuity tool, the department reduced the hours worked per equivalent patient days from 23 hours to 18.7 hours. This reduction was projected to save $800,000 a year, although it actually resulted in hospital savings of $1,300,000.

Implications for Nursing Practice These metrics demonstrate the benefits of an acuity tool in a daily nursing assignment sheet for safe patient care, improved nursing satisfaction, increased productivity, and financial savings.

Improving Retention through Implementation of a Nurse Externship Kristi J. Wilkerson, MS, BSN, Purpose for the Program RN, RNC-NIC, Baylor All his program was designed as a collaboration Saints Medical Center-Andrews between a local university, nursing students, Women’s Hospital, Fort Worth, and a community hospital. All shared a common TX

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desire to promote 1st-year retention for new graduates. Resumes and brief interviews with unit leadShelley Faber, BSN, RN, ership are often the only information available for RNC-NIC, Baylor All Saints hiring decisions. Leaders express concern over Medical Center-Andrews Women’s Hospital, Fort Worth, the ability to choose appropriate candidates from TX limited interaction in the interview process. A primary program goal was to allow nurse leaders Keywords to better determine the success of potential emextern ployees through sustained interaction. For student externship nurse externs, participation was designed to exretention collaboration pand clinical experiences and assist in the transition from academia to professional practice.

Professional Issues Poster Presentation

Proposed Change To provide a mutual opportunity for informed decision making, a nurse externship was proposed. Student nurses were able to experience specialties within nursing to determine compatibility. Prospective employers were able to spend more time with potential employees to allow better determination of future employer–employee relationship success. Implementation, Outcomes, and Evaluation Care of the Neonate was a 10-week elective course for senior nursing students that included didactic content, skills labs, case studies, and quality improvement projects. The externship was dedicated to hands-on experiences under the di-

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rection of a clinical coach. Patient assignments, conferences, and learning activities were designed to address cognitive, affective, and psychomotor learning domains. Externs compiled a portfolio linking clinical objectives to outcomes. These were evaluated by program facilitators, clinical coaches, and extern participants to determine successful completion. A Likert-type scale questionnaire showed an increase in confidence, time management, and critical thinking skills. Externs unanimously reported decreased anxiety and increased perception as valued health care team members. Unit leaders were able to confidently select appropriate candidates for employment and continued to experience 100% retention beyond the 1st year of employment for all externs hired. Implications for Nursing Practice Studies indicate that investment into an externship can increase nurse retention. Externships allow novice nurses to practice skills, increase confidence levels, become inside members of the health care team, and develop communication skills with patients, families, and other health care providers. Throughout the literature, nursing students, nurse educators, and employers expressed concern over the lack of hands-on learning and practice readiness that academic clinical time provides new nurses. Provision of additional clinical time and skill repetition, as in an externship program, is reported to increase confidence, reduce anxiety, and promote critical thinking.

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Enhancing Clinical Support and Collaboration through Creation of a Standardized Critical Event Debrief Process Purpose for the Program bstetric-related critical events are selfdefined, often unexpected, traumatic events with the potential to involve multiple staff members that result in strong emotional responses for which usual coping mechanisms may be ineffective. Health care professionals are trained to clinically respond to patient-related events; however, they may not have the resources to adequately respond to emotions triggered by these events. Health care providers in these situations may have feelings of worry or grief after the event. If these feelings are not addressed, they may lead to increased stress, hindrance of the ability to provide good care, and burnout. Debriefing is a group meeting arranged for the purpose of recounting and fact gathering after a critical event has occurred. The purpose is to help review processes and improve clinical practice, provide staff with emotional and psychologic support, and foster teamwork.

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Proposed Change To conduct a standardized debrief with the individuals involved in a critical event to help staff members discuss the event and identify who may need additional clinical or emotional support. Implementation, Outcomes, and Evaluation This hospital created a standardized debrief tool for utilization in newly established critical event

debriefs. Critical events were described as selfidentified and included near misses, significant medication errors, and adverse events. As frontline leaders, unit-charge nurses were the targeted group for initial education on the new, hospitalwide, critical event debriefing process. They were educated on the purpose and importance of conducting a timely and confidential debrief after a critical event. The newly developed paper tool was presented to this group along with a discussion of the phases of debriefing that were used to structure the tool and common factors that may enhance or hinder an individual’s response to the event. A counselor from the Employee Assistance Program was brought in to teach nurses how to conduct an emotional debriefing session. Feedback since implementation of the debriefing process has provided clinicians and the organization with valuable information that has been used to improve patient care and processes, communication between departments, and teamwork.

Susan Faron, MN, RNC-OB, CNS, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Jacqueline B. Hiner, MSN/Ed, RNC-OB, CNS, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Jacqueline B. Hiner, MSN/Ed, RNC-OB, CNS, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA Keywords debrief critical event support teamwork

Professional Issues Poster Presentation

Implications for Nursing Practice Empowering frontline leaders with the tools and resources to conduct debriefings after critical events is crucial to help review and improve clinical practice. In addition, the debriefing session provides a safe place to examine feelings, thoughts, and responses to the event to allow nurses to prepare for potential future events.

A Comprehensive Leadership Response to an Unexpected Maternal Death Purpose for the Program he purpose of this presentation is to describe the successful development and implementation of a leadership pathway for response to an unanticipated, maternal death during pregnancy. The pathway is comprehensive and addresses family support, staff support, risk management, regulatory notification, and media response planning for short term and long term periods and may be individualized to a specific institution and area of practice.

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Proposed Change Development of a leadership pathway that can be tailored to a variety of settings. Responses of leadership can vary after a catastrophic event there-

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fore, the pathway will ensure that all areas for re- Faye J. Weir, MSN, RN-C, sponse and support are assessed and addressed South Shore Hospital, South Weymouth, MA as needed. Keywords maternal death leadership Implementation, Outcomes, and Evaluation support Implementation of the pathway is individual- pathway

ized and occurs after an unanticipated, catastrophic event (such as a maternal death) and is based on leadership and organizational need. The outcomes will demonstrate that all areas are assessed and appropriate action plans implemented. Evaluation of effectiveness of pathway will be done at the user level, whereby they may make additional modifications based on staff/family and colleague feedback.

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Weir, F. J.

Proceedings of the 2015 AWHONN Convention

Implications for Nursing Practice In the published literature, leadership response in cases of unanticipated maternal death is limited to debriefing with staff. The literature does

not address the comprehensive response plan or any type of guide/pathway that the user may implement/modify as necessary. Additional research regarding a comprehensive response program related to staff support is necessary.

Social Media and Professional Boundaries in the NICU Setting Shanita D. Lofton, BS, BSN, Purpose for the Program RN, CCRN, Baylor All Saints search of online databases provided eviMedical Center, Fort Worth, TX Keywords social media professional boundaries social media violations

Professional Issues Poster Presentation

Proposed Change To determine if the implementation of a structured social media education program would increase neonatal intensive care unit (NICU) nurses’ understanding of professional boundaries when using social media networks.

professional boundaries when using social media platforms was presented to staff in the NICU at Baylor All Saints Medical Center. Following the presentation, a postsurvey was sent to see if there was an increase in staff awareness. Postsurvey results indicated that 100% of staff surveyed are now aware of the differences between professional and personal relationships; 95% of staff are now aware of the Baylor Health Care System Social Media Policy; and 76% of staff are now familiar with the National Council of State Boards of Nursing position on social media use. These results show an improvement in staff awareness about social media and professional boundaries when using social media sites.

Implementation, Outcomes, and Evaluation A presurvey was conducted to assess staff understanding of social media and professional boundaries. After completion of the presurvey, an educational presentation about how to maintain

Implications for Nursing Practice Further studies are warranted to determine if nurses will change behavior regarding social media now that they are more knowledgeable about the issue.

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dence that nurses are not sure about how to maintain professional boundaries when using social media sites. Concerns about how to protect staff members from potential social media violations led to the development of an evidence-based practice project to address the issue.

Implementation of a Formal Charge Nurse Leadership Development Program Jenny L. Graves, MSN, RN, Sigma Theta Tau, Baptist Health Richmond, Richmond, KY Gail A Reichert, MSN, RNC-OB, Baptist Health Richmond, Richmond, KY Keywords innovative charge nurse leadership development women’s care trailblazers empowerment

Professional Issues Poster Presentation

Purpose for the Program hat happens to a unit within a hospital setting that has no formal leaders? The unit becomes stuck in survival mode. This was the history of the women’s care unit in a 105-bed hospital, where fewer than 800 neonates are born annually. With many obstacles and traditional thinking hardwired into everyday practice, developing a formal training program for charge nurses was a new way of thinking for the unit staff and the rest of the hospital. Our program has turned into a pilot project for the rest of the hospital.

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There were many years during which the women’s care unit was without consistent, formal leadership. Out of necessity, several senior, proactive nurses stepped into charge nurse roles. With no formal training or higher level management support, the women’s care unit was the only unit in the hospital that had informal nurse leaders as front-

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line management. The undeveloped charge nurse role carried no authority to staff or to other areas within the hospital. Proposed Change The Women’s Care Charge Nurse Leadership Development program was created based on a review of the limited, current literature. One of the goals during the development of the program was to ensure that all training aligned with the mission, vision, and values of the hospital. The training action plan was approved by the chief nursing officer. A timeline was set up to complete the initial training within 6 months, which was a lofty but not impossible goal. Implementation, Outcomes, and Evaluation The program included three sessions with the first used to discuss the charge nurse role, job

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description, competencies, responsibilities, and expectations. The second session was an obstetric medical–legal brief, which was specific to the legal aspects of the charge nurse role in the women’s care setting. The final session was designed to cover a broad spectrum of topics such as team building and strength-based teamwork, leadership styles, incident reporting, human resource scenarios, conflict resolution, pa-

tient safety, perinatal risk management, and communication styles. Implications for Nursing Practice The effect of this training has been multifold, as each charge nurse has a sense of purpose, is aware of the expectations and has specific guidelines to follow, has been set up to succeed, and has confidently embraced the charge nurse role.

Preparing the Next Generation of Perinatal Nurses at Hawai’i Pacific Health Perinatal Nursing Academy Purpose for the Program erinatal nursing positions are among the most critical to fill. Nationally, there exists an overall nursing shortage, whereas locally, we have a surplus of new graduate nurses. This presentation explores the innovative approaches that our organization used to enhance our ability to bridge experienced and new graduate nurses into perinatal nursing.

tation and Education Program modules, integration of simulation training, and on unit precepting. Additionally, the Perinatal Nursing Academy involves a gradual introduction of topics where participants are brought to the classroom for lecture intermittently during the first 15 weeks of a 20-week training program. This allows for delivery of content, absorption, application, and then questioning based on real-life experience in the classroom setting.

Proposed Change To create a flow of nurses to fill the most critical nursing area positions, an extensive initiative called the nursing pipeline was established throughout Hawai‘i Pacific Health. The goals of the initiative included delivering state-of-the-art training to ensure the highest quality of care and create a process in which internal registered nurses (RNs) currently holding clinical assistant positions were identified and selected for training opportunities.

The Perinatal Nursing Academy has trained 43 labor and delivery RNs with a 98% pass rate and a 96% 2-year retention rate. Data indicate that Academy nurses demonstrate significantly higher employee engagement scores than the general nursing population. We remain front runners in the state in getting this type of training to our nurses and addressing the community need to hire local new graduate nurses to avoid relocation to the mainland to seek employment.

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Implementation, Outcomes, and Evaluation The redesigned Perinatal Nursing Academy uses a structured, validated, didactic curriculum following the Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) Perinatal Orien-

Bridget Lai, BSN, RNC, Kapiolani Medical Center for Women and Children, Honolulu, HI Keywords perinatal training new graduate

Professional Issues Poster Presentation

Implications for Nursing Practice The initiative creates a best practice approach that positions organizations to ultimately provide the best patient care using the highest trained nurses for the best outcomes while addressing the community need.

Improving the Delivery of Care to Limited English Proficiency Patients Purpose for the Program imited English proficiency (LEP) creates challenges for effective communication, affects health outcomes, and exacerbates health disparities. A survey of postpartum women at this facility indicated that 41% of LEP patients reported an unmet need for an interpreter and wide use of unqualified interpreters during their stays.

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Linda Daniel, MSN, RN, Proposed Change By October 2013, to achieve a 50% reduction in CPHQ, Christiana Care Health the number of postpartum LEP women who re- Services, Newark, DE ported an unmet need for a qualified medical interpreter (MI) during their hospital stay.

Implementation, Outcomes, and Evaluation A Lean Six Sigma (LSS) project was initiated to improve the quality and safety of care for women with

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Daniel, L.

Proceedings of the 2015 AWHONN Convention

Keywords limited English proficiency (LEP) culturally sensitive care communication disparity language barriers

Professional Issues Poster Presentation

LEP during their labor and delivery hospitalizations. Utilizing LSS concepts, a multidisciplinary team embraced the define, measure, analyze, improve, and control (DMAIC) process. Focus groups and surveys were conducted to elicit the voice of the customer from patients, nurses, and providers. Findings from a postpartum survey served as the baseline of measure for unmet needs for an interpreter in LEP patients. The number of patients with a completed “preferred language” field in the patient registration and billing system (PRBS) as well as use of qualified interpreters (in person and telephonic) were tracked. A standardized process (script) for soliciting the patient’s preferred language was established and education on race, ethnicity, and language was provided. Obstetric providers received training on the use of language services and effective communication. After training, there was a 25% increase in completed preferred language fields in PRBS. There was a significant increase (34%) in

the use of qualified medical interpreters (p < .01) and (41%) in the use of phone interpreters (p < .01). There was also a significant reduction (75%) in the number of LEP patients who reported an unmet need for qualified interpreters (p < .001). Implications for Nursing Practice Effective communication is critical to the delivery of safe, high-quality care. Identifying and delivering safe, high-quality care to patients with LEP can be challenging. Failure to address language barriers inadvertently affects health outcomes. National efforts are underway to address disparities in care. As direct care providers, nurses must appreciate the importance of providing culturally sensitive care to avoid miscommunication and misunderstanding. Nursing administrators need to recognize the challenges associated with caring for the LEP patient and advocate for appropriate support and resources to meet the needs of LEP patients and health care providers.

An Interdisciplinary Approach to Creating a Culture of Safety Sara Pasciolla, MSN-Ed, Purpose for the Program RNC-EFM, New York t New York Presbyterian Weill Cornell MedPresbyterian Weill Cornell ical Center, potentially unsafe behaviors or Medical Center, New York, NY

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conditions have been observed on the labor and delivery unit. We demonstrate the successful imBarbara Alba, RN-IBCLC, New York Presbyterian Weill Cornell plementation of an innovative program to improve Medical Center, New York, NY the culture of safety within the obstetric unit with a goal to improve outcomes. Keywords culture of safety TeamSTEPPS senior administrative safety session

Professional Issues Poster Presentation

Proposed Change To use TeamSTEPPS as a basis and transform a less safe working environment into a safer, more collaborative, working environment. Implementation, Outcomes, and Evaluation A formalized plan for a culture of safety was gradually introduced to the obstetric department. Before the initial culture of safety roll out, an Agency for Healthcare Research & Quality (AHRQ) survey was completed by staff members. Formalized TeamSTEPPS training set the framework for communication tools and modalities that would be the expectation in all obstetric areas. Eighty-five percent (450 members) of the obstetric team completed TeamSTEPPS training by September 2014. Once staff had an understanding of the plan, leadership from nursing, obstetrics, and anesthesia were able to promote the use of tools, including multidisciplinary briefs, huddles, and debriefs, which created a general, nonpunitive, transparent department. This is demonstrated by a 45% in-

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crease in medical event reporting across all specialties from January 2013 to August 2014. Evaluation Metrics: Over a 2-year interval, increases were noted in the following domains of a Culture of Safety survey: (a) When patient safety issues or events were identified and reported to leadership, staff response indicated a 6% increase in feeling that their issues were heard; (b) When patient safety issues or events were identified and reported to leadership, staff response indicates a 14% increase in feeling that action was taken to address the event; (c) When patient safety issues or events were identified and reported to leadership, staff response indicated a 13% increase in feeling the action taken/planned in response prevented future harm or similar events from occurring; (d) When patient safety issues or events were identified and reported to leadership, staff response indicated a 17% increase in feeling that feedback and communication are given about the event. Implications for Nursing Practice Adapting a transparent environment grants nurses the ability to discuss obstetric events and near misses rather than fear retaliation from reporting. The integration of a formal culture of safety program laid the roadmap for everyone to follow, set expectations, and generally changed the way members of the department interacted with one another.

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Development of a Nurse Staffing Model to Accurately Reflect Complexity and Intensity of Patient Care Needs in an Urban Academic Medical Center Purpose for the Program ur current staffing model, based on nursing hours per birth, does not accurately forecast registered nurse (RN) staffing needs during a 24-hour period. Researchers have shown that the number of nurses may influence perinatal outcomes, which highlights the need to accurately project appropriate staffing. Perinatal outcomes are influenced by adequate staffing.

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Proposed Change To identify a staffing model for our labor and delivery area that more accurately matched actual patient care needs. Academic medical centers (AMC) pose a unique staffing challenge because of the larger percentage of patients without adequate prenatal care and complex medical comorbidities. Our current productivity statistic that drives nurse staffing is number of births per day, which does not account for acuity or intensity of care. Eleven percent of patients are unaccounted for in our current model because their stays do not result in birth, yet they require nursing care (e.g., trauma, preterm labor). Variation also exists in intensity of care for a subset of women that lack adequate prenatal care and who have complex medical comorbidities. Implementation, Outcomes, and Evaluation Wilson and Blegen developed a staffing model that provides a standardized measurement of

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nursing productivity, skill mix, and workload intensity that can be used to measure and evaluate outcomes. Based on their model, we captured the amount and intensity of nursing care using the following calculation of total hours of care needed in a 24-hour period: number of births x standardized nursing workload allotted to each birth, labor evaluations/obstetric patients whose stays did not result in birth, and labor and delivery operating room time. During the month of April 2014, we tested our present model against the more comprehensive one developed by Wilson and Blegen and found that their model better captured the complexity and intensity of nursing care needs in our patient population. When we applied the Wilson and Blegen model to our data, we demonstrated a negative variance to budget of 6% rather than the actual budget overage of 8%.

Implications for Nursing Practice In summary, this model provides a way to accurately forecast RN staffing requirements based on patient care needs in our labor and delivery unit. Next steps involve application of this model for budget planning and development of tools for charge nurses to ensure appropriate staffing in real time.

JOGNN, 44, S6-S40; 2015. DOI: 10.1111/1552-6909.12664

Joan L. Torbet, PhD, RN, Hospital of the University of Pennsylvania, Philadelphia, PA Marleen Mulkeen, BSN, RN, Hospital of the University of Pennsylvania, Philadelphia, PA Lynn Stringer, PhD, WHNP-BC, FAAN, University of Pennsylvania, Philadelphia, PA Kate Fitzpatrick, DNP, MSN, RN, ACNP-BC, Hospital of the University of Pennsylvania, Philadelphia, PA Keywords nursing productivity labor and delivery staffing

Professional Issues Poster Presentation

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