The New England Nursing Informatics Consortium (NENIC) held its 17th annual symposium on April 26, 2019, to explore how nurses are using informatics and technology to transform healthcare delivery and patient care. This annual educational and networking symposium is offered through a joint provider agreement between NENIC and the Boston Children's Hospital.
The symposium offers access to national and regional informatics thought leaders, as well as the opportunity for networking and exchanging of best practices. The program has a call for participation that brings tremendous innovation from the community to the program. Poster abstracts are submitted and then reviewed by senior NENIC members; NENIC manages the review process, which includes screening for rigor and credibility. It differs from other more traditional review committees in that there is a strong emphasis placed on mentorship of novice abstract writers. Poster abstracts may be returned to authors multiple times with reviewer suggestions on how to improve the formatting, the content, the general writing quality, and even the use of references. Along with member development, this rigorous process ensures professional, diverse, innovative, and exciting presentations. NENIC identifies a few posters to bring to the greater audience in a program session known asMember Highlights. This is the organizations effort to highlight local nurse leaders, informaticists, and innovation.
In 2019, there were over 27 abstracts submitted and accepted from across New England. The following top 10 abstract key words offer insights into where informaticists are focusing their energies: (1) clinical documentation, (2) data-driven quality improvement, (3) patient safety, (4) clinical decision support, (5) medication reconciliation, (6) standardization, (7) process improvement, (8) communication, (9) plan of care, and (10) patient care.
The selection for the members highlights session is one that seeks to showcase diverse practice environments, organizational size, and practice challenges. The session also supports the NENIC mission of highlighting nurses who are transforming healthcare through informatics.
Here are four of the 2019 abstracts that were presented in the Member Highlights session of the day. They are available at https://www.nenic.org/2019-poster-abstracts. Additional presentation materials can be found on the NENIC Web site (http://nenic.org).
Improving User Efficiency With Plan of Care Automation
Naomi Mercier, DNP, RN, Traynor Canny, MBA, Courtney Green, RN, MS, Mary Hudson, MS, RN, Christine Suchecki, MSN, RN, Mary Swenson, MBA, RN
Partners Healthcare, Boston, MA.
Introduction/Background: Automation of nursing care plans ensures patient problems are addressed appropriately and efficiently. Partners nursing informatics leaders developed a process to prioritize nine automated patient problems that are aligned with the National Patient Safety Goals and NDNQI measures.
Methods: Several Enterprise Clinical Content Build-Out sessions were held to review, update, and streamline the content of the nine plan-of-care problems selected for automation. In version 1, due to software limitations, the user was unable to customize goals and interventions before the problem populated the plan of care. Given this limitation, the subject matter experts focused on including the minimum necessary goals and interventions for each problem. The clinical informatics team applied an Agile framework for this effort.1 User workflows were evaluated to define appropriate decision support inclusion and exclusion criteria logic to automate each problem. Logic for this automation includes a specific order, assessment, patient class, and encounter type. The automation of plan-of-care problems was communicated and educated through creation of tip sheets that outlined the automation criteria for each.
Results: The nine problems are automated for most patients during their hospital encounter. The problem automation count correlates with the patient department as illustrated in the table below. For example, perioperative departments have higher counts for central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) problems due to the number of assessments they enter for urinary and central catheters. Requests for automating additional plans of care continue to be submitted and evaluated.
Discussion/Conclusion: End user feedback is positive. Nurses see evidence that their documentation is used by the system's decision support algorithms to automate building a relevant plan of care while saving clicks and streamlining documentation workflows. However, some have concerns that the automatically generated plans of care lack patient individualization. Currently, design changes are being evaluated to streamline personalization of the plan of care from the Best Practice Advisory alert. Future work includes additional automation based on specific patient criteria. End user feedback and analytics inform iterative adjustments to the decision support logic.
Reference
1. Agile Alliance. https://www.agilealliance.org/agile101/. Accessed March 9, 2019.
Assessment, Creation and Adoption of a Sepsis Trigger Tool in the EHR
Danielle Perley, BSN, RN, CPHON
Boston Children's Hospital, Boston, MA.
Introduction/Background: Identifying and providing quick, appropriate care have been the focus of the Surviving Sepsis Campaign since 2002 with the most recent guidelines published in 2016.1 With one million patients diagnosed with sepsis each year,2 the awareness of the diagnosis is increasing. There are many opportunities to increase awareness to the need for quick diagnosis, as well as improve treatment options. With increased awareness, there is the opportunity for inappropriate testing and treatments.3
Methods: Clinical decision support tools must balance increased awareness with the need to protect the patient from unnecessary care. Boston Children's Hospital adopted Sepsis Trigger tools for utilization in the ICUs, general medical inpatient floors, and the neonatal ICU. The Sepsis Initiative Workgroup at Boston Children's Hospital requested to build an intricate tool within the nurse's current workflow. The request was for a very intricate tool. So as not to create excessive alerting,4 a multidisciplinary task force created a large, conditional logic-based tool within the nursing flowsheet.
Results: The tool is based on conditional logic and nomenclature-based scoring with background calculations. In addition, the tool supplies interpretation of discrete fields so the nurses can remain within their workflow. This decreases the need to exit it in order to check reference materials.
Discussion/Conclusion: The tool is now monitored to maintain usage in the initial adoption areas.This includes intermittent chart audits and data collection through our data warehouse. The tool has been integrated into policy in order to ensure it is being used to capture early signs of sepsis.
References
1. The Society of Critical Care Medicine (2018) Surviving Sepsis Campaign: guidelines. http://www.survivingsepsis.org/Guidelines/Pages/default.aspx. Accessed March 9, 2019.
2. Backer DD, Dorman T. Surviving Sepsis Guidelines: a continuous move toward better care of patients with sepsis. Journal of the American Medical Association. 2017;317(8): 807-808.
3. McCulloh RJ, Fouquet SD, Herigon Jet al. Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project. Journal of the American Medical Informatics Association. 2018;25(9): 1175-1182.
4. Hussaain S, Dewey J, Weibel N. Reducing alarm fatigue: exploring decision structures, risks, and design, European Alliance for Innovation Endorsed Transactions on Pervasive Health and Technology. 2017;17(10).
Developing an Intensive Care Unit Acuity Tool
Laura Ritter-Cox, MSN, RN-BC, Sharon C. O'Donoghue, DNP, RN, Robert Lombardo, MSN, RN, CCRN
Beth Israel Deaconess Medical Center, Boston, MA.
Introduction/Background: Patient acuity refers to the physical and psychological complexity of patients. Tools have been developed to assess the complexity of a patient assignment, nursing workload, and plan for future staffing patterns. The Therapeutic Intervention Scoring System 28 (TISS-28) was a scoring system developed in the 1970s as a means of stratifying patients by severity of illness and then evolved as a measure of nursing workload in relation to the nursing needs of the patient.1 Data from the electronic medical record can be pulled to identify the TISS-28 score without the need for nurses to manually enter information. Massachusetts law requires all ICUs to have an acuity tool to assess the level, intensity, and nursing needs of patients in order to provide appropriate staffing levels.
Methods: A modified TISS-28 tool, which was developed for another project at Beth IsraelDeaconess Medical Center, was used as a starting point to assess its accuracy. It was determined that certain technologies were not being addressed in this scoring system as designed and updates were made to reflect this increased acuity and workload. One auditor with specific instructions chose one day and time and scored every patient at that point in time to ensure interrater reliability.
Once the tool was validated, a developer in the IS department extracted the data from our documentation system and built a dashboard to display the acuity scores. The modified TISS-28 scores were manually compared to patient assignments on every ICU patient to validate if the most highly acutely ill patients were being scored and singled appropriately.
Results: After validating the modified TISS-28, the scores were added to a capacity dashboard accessible by all staff to assist in making patient assignments. Additionally, the capacity dashboard is used to manage throughput at a meeting twice a day where representatives from each ICU meet and share their census and staffing needs to ensure each unit is staffed appropriately. The scores were stratified into three levels: low 12-25, 26-35 intermediate, and >36 high, giving some guidance as to which patients may require one-on-one care and which patients may be appropriate for 2:1 care. The scores are only a guide and provide an objective measure to support nursing judgment while making patient assignments.
Discussion/Conclusion: The Massachusetts Department of Public Health certified the use of our tool and accompanying decision algorithm as a guide for nurse/patient assignments in our ICUs. Along with input from the bedside nursing staff, this tool will aid in the process of patient assignment, but will not replace sound nursing assessment and judgment of the clinical situation.
Reference
1. Katz A, Andres J, Scanlon A. Application of Therapeutic Intervention Scoring System (TISS) to an electronic health record: a feasibility study. Pediatrics. 2018;141. doi:10.1542/peds.141.1_MeetingAbstract.321.
Implementation of Digital Whiteboard and Interactive Patient Education and Care Application
James Scheurell, BS, Sarah Wright, MSN, RN
Nantucket Cottage Hospital, Nantucket, MA.
Introduction/Background: With the recent completion of a new hospital, Nantucket Cottage Hospital (NCH) evaluated the advantages to utilizing new digital technology to replace the standard dry erase whiteboard in the patient rooms. The standard board was historically updated manually with patient demographics, key vitals, and care team information and would often lag behind with up-to-date information. NCH chose to implement a hardware and software solution in 14 patient rooms. The goal of the project was to digitize patient information from the whiteboard and integrate it with the electronic health record (EHR). The application selected brought with it the ability to assign patient education on various topics in both English and Spanish. In this poster, we describe the decisions, challenges, successes, and future scope of the digital whiteboard project at NCH.
Methods: NCH used a standard healthcare information technology project management approach to the implementation of this new software. NCH had on-site demos from the vendor and workflow observations/discussions as well as user interface design sessions and patient education video selection. Based on initial findings and discussions, we scheduled meetings with clinical management, information technology, and NCH senior leadership to reach final user interface design sign-off. The NCH nurse educator was a key decision maker in selecting the patient education videos that we would offer to the staff for assignment to patients. Selection was prioritized and based on our most frequent diagnoses as well as specific prioritization for our labor and delivery patients.
Results: The digital whiteboard was live the moment we moved our first patients into the new hospital on February 20, 2019. The patients were welcomed into their new rooms with the date, their name, the names of their care team, their room number, room phone number, identified support person, and a short NCH-focused informational video on a 49-inch Smart TV. All of this content was integrated so that updates made in the EHR would, in real time, update the information in the patient room. This was made possible by a live ADT (Admission, Discharge, Transfer) HL7 unidirectional interface with the EHR. The patient pillow speaker was fully integrated with the TV controls, as well as the nurse call system. Through the use of the pillow speaker, the patient can easily investigate the multiple options for viewing cable TV, free movies, and health-related videos, as well as relaxation content. The nurses can work with each patient to "bookmark" health-focused videos specifically addressing individualized education needs.
Discussion/Conclusion: The feedback from patients and staff has been very positive, and a set of key performance metrics is scheduled to be evaluated to more discretely capture project success. There were also several technical challenges such a server configuration, network connectivity, and hardware setup that will be presented. The NCH Clinical Business & Technology team continues to work closely with the Partners eCare EHRclinical teamto identify patient-specific information that will be mapped for display. With an additional DocFlowsheet HL7 interface, clinical information such as goals for the day, last pain scores, fall precaution icons, activity limitations, and newborn weights and feedings will be pulled in real time from the EHR to our patient screen. There are also operational plans to map available videos to commonly chosen plan-of-care patient education interventions.
References
1. Dunn N. Initial experience: an in-house look at the comparison between a digital whiteboard to the traditional patient tracking system. The Journal of Nuclear Medicine. 2018;59 suppl 1 2126(1).
2. Goyal AAet al. Do bedside visual tools improve patient and caregiver satisfaction? A systematic review of the literature. Journal of Hospital Medicine. 2017;12(11): 930-936.