This initiative’s purpose was to reduce the catheter line-associated blood infection incidence rate (CLABSI) in the medical intensive care unit (MICU) to zero and maintain that rate by utilizing the best practice advisory (BPA) alert feature located in Epic, the institution’s EMR.

The 12-bed MICU of our urban full-service teaching hospital had 808 central line days for the first 5 months of 2021. During this time, the CLABSI incidence rate was elevated at a monthly average of 9.1.

Nursing informatics/quality brainstormed solutions to reduce the CLABSI incidence rate. We decided to utilize our pre-existing central venous line (CVL) maintenance order set and Epic’s clinical decision support systems (CDSS). We focused on prevention as the primary way to reduce the incidence rate. We developed the CVL maintenance order set from evidence-based practice (EBP) guidelines. This set contains orders that supports proper CVL flush protocols and various dressings, including CHG dressings for preventing infection.

The team observed that CVL maintenance orders were not always in place after central line insertion. Therefore, we leveraged BPAs, alerts that display when triggered by an action. They are a form of CDSS located within Epic. Our novel approach was to have the BPA trigger immediately after the documented placement of a CVL. Medical center information technology (MCIT) worked with Epic technical services to implement a programming solution that allowed for the following process: The provider signs the note, which triggers: 1) the CVL insertion order being added automatically and 2) the BPA alerts the provider to place the CVL maintenance order set.

After creating the BPA, testing involved monitoring its triggers for the right action and role. Go-live was on May 19, 2021. We used tools available in Epic to evaluate the BPA after implementation. The BPA fired in the MICU for 28 unique patients during the evaluative period (June –September). Of those 28 unique patients, 20 (71%) of the times, the provider placed a maintenance order; 7(25%), the provider chose the acknowledgement reason indicating that they placed the order outside of the BPA; and in 1 (4%) case the provider indicated they would place the order in the BPA, but no order was found. Our outcome measurement was the CLABSI incidence rate in the MICU. The rate dropped to zero from June through September 2021. The MICU had 235 central line days during this period.

Combining EBP and CDSS contributed to a significantly reduced CLABSI incidence rate in the MICU. To be effective, a CDSS alert should display for the user that has the most ability to act on it. Our innovative approach involved designing the BPA to fire when the provider signs the procedure note, right after physically placing the central line, which allowed informatics to target the alert to maximize its value. We suggest reviewing other BPAs (or similar CDSS tools in your EMR) that may also benefit from changing their triggering method.

The American Nurses Association’s Nursing Informatics Scope and Standards of Practice identifies compliance and integrity management as a core functional area of nursing informatics. The informatics nurse specialists advocates for protecting health information, ensuring the ethical use of patient data, maintaining the data’s integrity and security, and protecting the confidentiality of patient health information. Moving beyond EHR implementation, INS also play a key role in leveraging technology to optimize workflows in the healthcare setting.

The security informatics nurse specialists in the department of clinical research clinical informatics at the Clinical Center, National Institutes of Health (NIH), function in a unique position as advocates in protecting patient health information. The security INS is responsible for the oversight and management of end-user accounts for the clinical research information system (CRIS) electronic health record. This includes creating, modifying, and inactivating user accounts, as well as performing ongoing maintenance tasks surrounding access to the EHR application. The team supports EHR user accounts for all interdisciplinary staff (clinical and research) for the entire NIH community, which comprises of the clinical center and 27 institutes and centers. The security team INS is responsible for determining the security rights to assign to end users based on their roles and job functions, as well as the level of EHR training completed.

The user accounts process was initiated by the submission of the CRIS account request PDF form to the CRIS security team. This was followed by a series of steps to grant the user access to the EMR. However, the workflow was cumbersome for the requestor and the security INS. Deficiencies included misplaced/lost paper forms, inaccurate form completion, web browser limitations, and signature authentication issues. These led to end user delayed access to the EMR, user dissatisfaction, and ultimately disruption in the continuum of care. Moreover, there were administrative challenges with the storing and archiving PDF forms, as well as the retrieval and auditing of user access data. Remote work related to the COVID-19 pandemic added another layer of technical complexity in the process.

The team implemented a quality improvement project to streamline the user account process by developing a one-stop electronic process utilizing automated workflow technology. This involved forming an alliance and collaborating with a multidisciplinary team of stakeholders to revise user account policies and processes. The systems development life cycle framework was used to bring the project from inception to completion. End user acceptance was vital to the success of this project. The project results were decreased administrative workload, improved communication, user interface, simplified workflow, and increased user satisfaction.

Elements of care require documented patient consent and patient care staff need to review required consent prior to performing care. Paper consent forms are completed by handwriting required elements such as “procedure” and “risks,” and then the provider and consenting party provide signatures. If handwriting is illegible, the paper consent form is misplaced or the consent is not readable due to poor scanning technique, procedures can be delayed and present a patient safety risk. Electronic consent workflows can improve the quality of this process and reduce potential patient safety issues. Employing principles of a quality improvement framework, our institution initiated an enterprise-wide implementation of an electronic consent workflow. Our initial experience has shown improvements in consent completion.

After the identification of areas with higher consent volume, a new feature in our electronic health record (EHR) was rolled out one department at a time. Staff had the ability to access specific department phrases and terms to assist with creation of the consent. Ease of use, familiarity with the HER, and targeted staff training supported user adoption. To support review and consent by the consenting party, dedicated patient/family tablet devices were deployed to each area as part of implementation. Consenting parties also had the option to review and sign via patient portal.

Process mapping of current and future consent workflow was completed to assist with understanding the associated steps and responsibilities. Additionally, to understand current state practice, a manual audit of institution-based consent-related incident reports was completed. To assist with evaluation of this implementation, review of pre- and post-implementation consents by department were completed. Post-implementation results found electronic consents 100% of the time and all required elements of the consent were legible. Our results support the potential of this workflow to decrease risks to patent safety and increase efficiency by removing the delay of finding a paper consent, finding a consent that had been scanned but is not easily read, or finding a consent that is illegible. Tracking adoption of this process by department has also been set up and will inform leadership of any need to further investigate implementation issues or need for training support.

Adding simulation encourages subject matter experts and non-experts to gain more insight in to not only how a piece of technology can improve their process on the unit, but also other factors that may impact that process. In the traditional system development life cycle (SDLC), clinical informatics can use the flexibility and partnership with information services for the best time to incorporate a simulation and come with the best outcome for patient safety and customer satisfaction.

The presentation will share how the clinical informaticist led a large healthcare system in collaboration with the simulation and information services (IS) partners develop a strategy for addressing challenges in supportive technology:
• Clarification of the goal to simulate a unit’s needs
•    Timely requirements from stakeholders and multidisciplinary areas to bring forth the resources to create the simulation
•    Accountability and evaluation from a clinical simulation

Participant will be able to:
•    Describe what simulations entails when implementing technology
•    Understand the details related to simulations and what departments to consider
•    Discuss how organizations can apply simulations as part of their SDLC in improving further build and/or processes
•    Describe the need for accountability from the end user for outcomes from the clinical simulation

Background/purpose: Meaningful use spurred healthcare systems to transition to using electronic health record (EHR) systems as a standard technology to capture vital data. Nurses use EHR systems as an essential part of their work as they monitor patients, document, communicate, and support direct patient care. To ensure all nurses can fully engage with this and other technology tools, the AACN developed revised competency expectations of nursing graduates at all levels. But a gap exists. Many schools of nursing lack the resources and faculty competency to fully use an EHR as part of education to meet the expected competencies. Identifying needs from a faculty perspective and providing evidence-based recommendations and guidance for EHR use and education could improve implementation of this needed technology and the competency to use the technology to its full potential.

Description: To determine self identified faculty competency gaps, a survey was developed as part of a needs assessment related to the use of an academic EHR during teaching at a large academic school of nursing. The survey assessed the faculty's awareness of the current system, perceptions of potential use to achieve competencies, and opinions of needed features. The anonymous survey was administered to nursing school undergraduate and graduate faculty within an academic medical center school of nursing.

Evaluation: Findings indicate that faculty believe that there is a benefit to incorporating an academic EHR system into teaching to increase competence of the students and deeper use of the EHR data and information. Deficits in how to incorporate an academic EHR into practice were noted among faculty. Detailed data will be available at time of the conference. Data is awaiting review and approval internally.

Conclusion: Increasing the use of technology within nursing education is a priority. Nursing faculty recognize that academic EHRs can be used to teach nursing informatics competencies. Not all faculty feel that they have the support and knowledge needed to execute this teaching strategy. Support should be offered to faculty when an academic EHR is in place to optimize the potential of the learning system.