What Goes in (The OR) Must Come Out

ASPAN NATIONAL CONFERENCE ABSTRACTS PACU DOCUMENTATION: TRANSITIONING FROM PAPER TO THE ELECTRONIC RECORD Team Leaders: Diane Fetterhoff, BSN RN CPAN, Patricia Craig, RN Pennsylvania Hospital, Philadelphia, Pennsylvania Team Members: Stephanie Setaro, MSN RN ACNS-BC, Theresa McMunn, BSN RN, Jessica Friedman, BSN RN, Francis R. Rinault, BSN RN Background: The implementation of the electronic medical record (EMR) has dramatically changed the workflow and documentation practices in the Post Anesthesia Care Unit. Although eight hour education classes and two weeks of onsite support were provided, documentation in the EMR was inconsistent and did not consistently meet required standards. Nursing handoffs were also impacted by difficulty finding the information necessary to deliver safe care. Prior to our intervention, an electronic survey was completed by all PACU clinical nurses to obtain qualitative data on specific documentation criteria and the results were found to be very diverse. Chart audits were also conducted to determine the degree of variation in documentation practices. Objectives of Project:  Establish guidelines for PACU documentation in the EMR  Promote standardization and decrease variation in the medical/health record  Increase accessibility of pertinent information by the entire perioperative team Process of Implementation: A committee was formed to establish guidelines for PACU documentation. After conducting a review of the current literature, including the ASPAN standards and The Joint Commission regulations, the committee developed guidelines based on the best available evidence and published standards. The guidelines were disseminated via email, “staff huddles”, staff meetings, and were posted on the intranet. Chart audits were performed monthly, and real time audits were performed at the bedside during handoffs to ensure documentation standards were being met. Education huddles were conducted to disseminate education on the audit findings and to answer process questions. Statement of Successful Practice: The initial audits were used as the baseline data to measure improvement. Five specific areas of documentation were reviewed in twenty random records. The post-intervention audits showed a significant improvement in compliance and were collected monthly following implementation of the EMR guidelines.

Note: All abstracts are printed as received from the authors.

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Implications for Advancing the Practice of Perianesthesia Nursing: Hospitals throughout the country are converting to Electronic Medical Records, which create opportunities for clinical nurses to lead change and improve documentation practices, impacting other disciplines and the quality of patient care. Creating and implementing evidence-based guidelines for EMR documentation improved the consistency and comprehensiveness of nursing documentation at our institution. The interdisciplinary health care team can now locate data in standardized locations, thus promoting efficiency, reducing variations of care, and creating safer handoffs.

WHAT GOES IN (THE OR) MUST COME OUT Team Leader: Vonda L. Davidson, BSN RN CPAN Hospital if the University of Pennsylvania, Philadelphia, Pennsylvania Team Member: Joseph Moffa, MSN BS RN NE-BC CCRN

Background Information: The staffing of the Post Anesthesia Care Unit (PACU) is contingent upon the daily schedule of 33 operating and procedure rooms. Efficient PACU patient flow plays an integral part in managing timely operating room flow and costs. Scheduling nurses on fixed shift templates often resulted in a lack of nursing staff present to recover patients or created imbalances that did not support the patient acuity level. These disproportions led to frustration and overall dissatisfaction among the nursing staff. At this institution we use a computerized patient tracking system which allows its users to visualize all patient activity. Icons are representative of the patient’s perioperative progress. This data enables the PACU charge nurse to anticipate the need for an available PACU nurse for patient recovery. Utilizing monthly patient flow graphs that depict the number of patients in the PACU and the time of day allows us to create a cost-effective nursing schedule to provide adequate staffing at the appropriate times in order to ensure patient safety. This analysis revealed that we had been staffing an insufficient number of nurses to accommodate the needs of the operating rooms at specific points of the day and an overabundance of staff at slower periods of the day. The data also demonstrated that our practice of staffing the same number of nurses each day of the week was not meeting the needs of the unit. In addition, patient safety net reports revealed OR to PACU delays that were reportedly due to inadequate staffing; the PACU received below average scores on the NDNQI RN Satisfaction Survey and there was an increase in the percentage of staff clocking out before the end of their shift, all indicating an inadequacy in our scheduling process. Objectives of Project: The purpose of this project was to ensure there were sufficient nursing staff in the PACU to accommodate the operating room throughout the day to deliver safe world class care. Process of Implementation: After in-depth review of patient flow activity graphs and utilizing ASPAN guided nurse- to- patient ratio recommendations it was identified that this institution was in need of five nursing FTE’s in addition to our current staff. This data support allowed for the approval and onboarding of five additional nurses in the PACU. A monthly review of patient flow activity is completed prior to each schedule being created. If the flow activity changed from the

ASPAN NATIONAL CONFERENCE ABSTRACTS

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previous month, the scheduler would evaluate and adjust the overall staffing compliment. This evaluation allowed for us to create a cost-effective nursing schedule that provides staff accordingly at the appropriate time ensuring patient safety and the delivery of world class care. Even with these implemented changes, the ability for nurses to self -schedule remained intact, which is a staff satisfier. Statement of Successful Practice: Hiring and onboarding additional nursing FTE’s, adjustment of daily staffing compliment and continuing self-scheduling allowed for this institution to totally eliminate delays and improve our NDNQI results. Over a two-year period, the PACU did not have any safety nets placed that pertained to OR to PACU patient flow. In addition, nursing staff worked their entire shift recovering patients and the long downtimes and leaving early was eliminated. In addition, our NDNQI results increased at a steady rate over a two-year period.

were updated monthly on unit’s success and opportunities for improvement. Education and updated policy information was conducted through email, staff meetings, and nurse reviews. Unit involvement was also supported by management with unit goals focused around the Press Ganey question “degree pain was controlled” in the perioperative setting and staff performed self-audits for their yearly nurse reviews. Statement of Successful Practice: Improvements in areas of documentation and meeting the pain goal were noted after implementation of interventions, but varied throughout the project. An increase in Press Ganey scores were also noted but varied. It is difficult to determine if improved document relates to an increase in patient satisfaction and may likely be a result of the overall unit focus and project on pain management. Implications for Advancing the Practice of Perianesthesia Nursing: EHRs will continue to provide opportunities for

NDNQI RN Satisfaction Results

2012 (completed as a T-score)

2013 (completed as a T-score)

2014 (Revised Scale version)

RN to RN Interacions Task T-Scores Job enjoyment Turnover Rate (%)

64.0 (, 50th) %tile 58.21 (, 50th) %tile 51.78 (, 50th) %tile 0%

67.26 (.50th) %tile 59.71 (.50th) %tile 55.92 (.50th) %tile 0%

5.52 (.75th) %tile 5.19 (.75th) %tile 74.95 (50-75th) %tile 0%

Implications for Advancing the Practice of Perianesthesia Nursing: Historical case data obtained from a computerized patient tracking system can be analyzed and used to predict daily patient load and create a cost effective nursing schedule.

FOCUSING ON PAIN: ENGAGING THE TEAM IN DOCUMENTATION CAN IMPACT OUTCOMES Team Leaders: Peggy Running, BSN RN CPAN CAPA, Sarah Wente, PhD RN Fairview Ridges Hospital Burnsville, Minnesota Team Member: Jan Nelson, BSN RN CPAN

Background Information: Documentation around pain and sedation is an important aspect of care in the PACU and Phase II. In nursing we know that if “it’s not documented it’s not done”. The implementation of Electronic Health Record Systems (EHR) has helped in some areas such as date/time stamp, legibility, but inconsistencies remain in pain documentation (Samuels and Kritter, 2011). A focus on pain management in the perianesthesia area was undertaken as a project for a hospital professional nurse advancement program to improve documentation, update staff around current policy, and examine patient satisfaction. Objectives of Project: To improve documentation of pain assessment, reassessment and the pain goal consistent with an updated policy. Educate staff and patients/families around the pain goal and increase number of patients meeting the pain goal at discharge to the floor. Improve understanding and documentation of sedation side effects of analgesia. Process of Implementation: Data was collected via audits prior to implementation and throughout the project. Staff Note: All abstracts are printed as received from the authors.

nurses to document pain management in the perianesthesia area. The various methods deployed in the project may be helpful for other organizations looking to improve pain and sedation documentation, along with Press Ganey.

WHEN THE SCREEN WENT BLACK: LESSONS LEARNED FROM FIVE DAYS OF DOWNTIME Team Leader: Mary Gibson, MSN RN CPN Boston Children’s Hospital, Boston, Massachusetts Team Members: Jessica Bruno, RN MSN CPNP, Gretchen N. Doonan, RN BSN CPN, Maryellen Mulcahy, RN BSN CPN, Valerie Vitale, RNC-NIC MSN CPNP

Background Information: In the present world of electronics and paperless medical records (EMRs), what are the implications for patient safety when that system is interrupted? During “downtime”, the electronic system for computer documentation and communication is inaccessible and requires modifications to routine workflow as well as communication between staff, patients, and families. In the aftermath of a prolonged down time experience which occurred spring 2015, the need to revise documentation, clarify communication methods, and further educate staff when confronted by limited resources was evident. Objectives of Project: Develop and implement an improved downtime process for utilization during an extended period of time when unable to access the EMR and electronic communication. Process of Implementation:  Analyzed the previous process for downtime  Identified areas for improvement  Obtained feedback from perioperative team